Form B21 - Statement Of Social Security Number
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1B 21 (Official Form 21) (12/07)
U
S
B
C
NITED
TATES
ANKRUPTCY
OURT
__________ District Of __________
In re __________________________________________,
)
[Set forth here all names including married, maiden,
)
and trade names used by debtor within last 8 years]
)
)
Debtor
) Case No. ______________
Address __________________________________________
)
__________________________________________
) Chapter _______________
)
Last four digits of Social-Security or Individual Taxpayer-
)
Identification (ITIN) No(s).,(if any): ___________________
)
_________________________________________________
)
Employer Tax-Identification (EIN) No(s).(if any):
)
_________________________________________________
)
STATEMENT OF SOCIAL-SECURITY NUMBER(S)
*
(or other Individual Taxpayer-Identification Number(s) (ITIN(s)))
1.Name of Debtor (Last, First, Middle):_______________________________
(Check the appropriate box and, if applicable, provide the required information.)
G Debtor has a Social-Security Number and it is: _____________
(If more than one, state all.)
G Debtor does not have a Social-Security Number but has an Individual Taxpayer-Identification
Number (ITIN), and it is: ______________
(If more than one, state all.)
G Debtor does not have either a Social-Security Number or an Individual Taxpayer-Identification
Number (ITIN).
2.Name of Joint Debtor (Last, First, Middle):___________________________
(Check the appropriate box and, if applicable, provide the required information.)
G Joint Debtor has a Social-Security Number and it is: ____________
(If more than one, state all.)
G Joint Debtor does not have a Social-Security Number but has an Individual Taxpayer-Identification
Number (ITIN) and it is: ______________
(If more than one, state all.)
G Joint Debtor does not have either a Social-Security Number or an Individual Taxpayer-Identification
Number (ITIN).
I declare under penalty of perjury that the foregoing is true and correct.
X _________________________________________________
Signature of Debtor
Date
X _________________________________________________
Signature of Joint Debtor
Date
*
Joint debtors must provide information for both spouses.
Penalty for making a false statement: Fine of up to $250,000 or up to 5 years imprisonment or both. 18
U.S.C. §§ 152 and 3571.
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