Declaration Regarding Administration Of Oath And Confirmation Of Identity And Social Security Number Form

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DECLARATION REGARDING ADMINISTRATION OF OATH AND
CONFIRMATION OF IDENTITY AND SOCIAL SECURITY NUMBER
In re: (Debtor’s Name)
Bankruptcy Case No.________________________________________________
Date of telephonic or video conference appearance at § 341(a) meeting of creditors: _________________
I declare as follows:
1)
_____________________________________________
My name is :
(Print or type)
2)
My work address is:_______________________________________
3)
My work telephone number is: (____)_________________________
4)
The address from where I participated in the § 341(a) meeting of creditors is:
______________________________________________________________________
5)
I am a person authorized to administer oaths in the State of ___________________, by virtue of
the following fact:
_____ I am a notary
_____ I am a court reporter
_____ I am a judicial officer
_____ I am authorized to give an oath under the Code of Military Justice
_____ Other: ________________________________________________
(Give title and legal authority for power to administer oath)
6)
I personally verified the identity of the debtor by checking his/her original photo identification:
_____ Drivers License (State & number) _____________________________
_____ State Identification (State & number)____________________________
_____ Passport (Country, number, expiration date) ______________________
_____ Military Identification (Branch & ID number) _____________________
_____ Other (describe) _____________________________________________
7)
I personally inspected the following original document as proof of the debtor’s social security
number and orally confirmed it with the trustee:
_____ Social Security Card
_____ Social Security Administration Statement
_____ W-2 Form
_____ Recent Payroll Stub
_____ Employer’s Health Card or Medical Insurance Card
_____ Other (specify) __________________________________________
8)
On ____________, I did administer an oath to the debtor, prior to the trustee commencing
(Date)
the questioning of the debtor for the telephonic or video conference interview of the debtor.
In accordance with 28 U.S.C. § 1746, I declare under penalty of perjury that the foregoing is true and
correct. Executed this ________ day of ________, ________, in _________________, _________.
(Date)
(Month)
(Year)
(City)
(State)
____________________________________________________________________________________
Signature of Person Administering Oath and Verifying Identity and Social Security Number

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