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Statement Of Social Security Number(s) 21 - Wisconsin
| Statement Of Social Security Number(s) Form. This is a Wisconsin form and can be used in USBC Eastern Federal . |
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Local Form 21 Rev:12/2012 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. UNITED STATES BANKRUPTCY COURT FOR THE EASTERN DISTRICT OF WISCONSIN In re_______________________________, Debtor Case No. _________________________ Chapter __________________ STATEMENT OF SOCIAL SECURITY NUMBER(S) 1. Name of Debtor (Last, First, Middle): ________________________________________ Debtor has a Social Security Number and it is _______ - ______ - _______ Debtor does not have a Social Security Number but has an Individual Taxpayer-Identification Number (ITIN), and it is: ______________________________ Debtor does not have either a Social Security Number or an Individual Taxpayer-Identification Number (ITIN). 2. Name of Joint Debtor (Last, First, Middle):________________________________________ Joint Debtor has a Social Security Number and it is _______ - ______ - _______ Joint Debtor does not have a Social Security Number but has an Individual Taxpayer-Identification Number (ITIN), and it is: ______________________________ Joint Debtor does not have either a Social Security Number or an Individual Taxpayer-Identification Number (ITIN). 3. Name of Spouse if not a Joint Debtor (Last, First, Middle): ________________________________________ Address ________________________________________ ________________________________________ Spouse has a Social Security Number and it is _______ - ______ - _______ Spouse does not have a Social Security Number but has an Individual Taxpayer-Identification Number (ITIN), and it is: ______________________________ Spouse 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 * Check the appropriate boxes above and provide the required information. * Debtor must provide information for non-filing spouse. * If Debtor, Joint Debtor or Non-Filing Spouse has more than one Social Security Number, state all. * Penalty for making a false statement: Fine of up to $250,000 or up to 5 years imprisonment or both. 18 U.S.C. ยงยง 152 and 3571. American LegalNet, Inc. www.FormsWorkFlow.com
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