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Statement Of Social Security Number(s) B21 - Official Federal Forms
| Statement Of Social Security Number(s) Form. This is a national form and can be used in General Bankruptcy . |
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B21 (Official Form 21) (12/12) 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 _______________ District In re __________________________________________, [Set forth here all names including married, maiden, and trade names used by debtor within last 8 years] Debtor Address __________________________________________ __________________________________________ Last four digits of Social-Security or Individual TaxpayerIdentification (ITIN) No(s).,(if any): ___________________ _________________________________________________ Employer Tax-Identification (EIN) No(s).(if any): _________________________________________________ Of _______________ ) ) ) ) ) Case No. ______________ ) ) Chapter _______________ ) ) ) ) ) ) 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 X ______________________________________________ Signature of Debtor Date ______________________________________________ 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. ยงยง 152 and 3571. American LegalNet, Inc. www.FormsWorkFlow.com
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