Form 121 - Statement About Your Social Security Numbers

Download a blank fillable Form 121 - Statement About Your Social Security Numbers in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 121 - Statement About Your Social Security Numbers with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Fill in this information to identify your case:
United States Bankruptcy Court for the:
District of __________
__________ District of __________
__________
Case number
_________________________
(If known):
Official Form 121
Statement About Your Social Security Numbers
12/15
Use this form to tell the court about any Social Security or federal Individual Taxpayer Identification numbers you have used. Do not file this
form as part of the public case file. This form must be submitted separately and must not be included in the court’s public electronic records.
Please consult local court procedures for submission requirements.
To protect your privacy, the court will not make this form available to the public. You should not include a full Social Security Number or
Individual Taxpayer Number on any other document filed with the court. The court will make only the last four digits of your numbers known
to the public. However, the full numbers will be available to your creditors, the U.S. Trustee or bankruptcy administrator, and the trustee
assigned to your case.
Making a false statement, concealing property, or obtaining money or property by fraud in connection with a bankruptcy case can result in
fines up to $250,000, or imprisonment for up to 20 years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571.
Part 1:
Tell the Court About Yourself and Your spouse if Your Spouse is Filing With You
For Debtor 1:
For Debtor 2 (Only If Spouse Is Filing):
1. Your name
_________________________________________________
_________________________________________________
First name
First name
_________________________________________________
_________________________________________________
Middle name
Middle name
_________________________________________________
_________________________________________________
Last name
Last name
Part 2:
Tell the Court About all of Your Social Security or Federal Individual Taxpayer Identification Numbers
2. All Social Security
__ __ __
__ __
__ __ __ __
__ __ __
__ __
__ __ __ __
Numbers you have
used
__ __ __
__ __
__ __ __ __
__ __ __
__ __ __ __ __ __
ou do not have a Social Security number.
You do not have a Social Security number.
Y
3. All federal Individual
9
9
__ __
__ __
__ __ __ __
__ __
__ __
__ __ __ __
Taxpayer
Identification
Numbers (ITIN) you
9
9
__ __
__ __
__ __ __ __
__ __
__ __
__ __ __ __
have used
You do not have an ITIN.
You do not have an ITIN.
Part 3:
Sign Below
Under penalty of perjury, I declare that the information
Under penalty of perjury, I declare that the information
I have provided in this form is true and correct.
I have provided in this form is true and correct.
_______________________________________
_______________________________________
Signature of Debtor 1
Signature of Debtor 2
Date _________________
Date _________________
MM / DD / YYYY
MM / DD / YYYY
Official Form 121
Statement About Your Social Security Numbers
Print
Save As...
Reset

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Esd-ark-223 (b) - Social Security Number Correction - Arkansas Employment Security Department Form Esd-ark-223 (b) - Social Security Number Correction - Arkansas Employment Security Department Legal
Form Modes-4427 12/07 - Social Security Number Correction Form - Missouri Department Of Labor And Industrial Relations Form Modes-4427 12/07 - Social Security Number Correction Form - Missouri Department Of Labor And Industrial Relations Legal
Form Esd-ark 223 (b) - Social Security Number Correction January 2001 Form Esd-ark 223 (b) - Social Security Number Correction January 2001 Legal
Confidential Statement Of Taxpayers Social Security Number Template Confidential Statement Of Taxpayers Social Security Number Template Legal
Statement Of Social-security Number Or Individual Taxpayer-identification Number (itin) Statement Of Social-security Number Or Individual Taxpayer-identification Number (itin) Legal
Your Social Security Statement Template Your Social Security Statement Template Legal
Social Security Number Application Process For F-1 International Students With Social Security Letter Social Security Number Application Process For F-1 International Students With Social Security Letter Legal
Form Ssa-89 - Authorization For The Social Security Administration (ssa) To Release Social Security Number (ssn) Verification Form Ssa-89 - Authorization For The Social Security Administration (ssa) To Release Social Security Number (ssn) Verification Legal
Statement Of Social-security Number Statement Of Social-security Number Financial
Statement Of Social Security Number Form Statement Of Social Security Number Form Legal

Related Categories

Parent category: Legal
Download
Go