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Statement Of Social Security Numbers B21 - Kentucky
|Statement Of Social Security Numbers Form. This is a Kentucky form and can be used in Eastern District Bankruptcy Court Federal .||
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Form B 21 Official Form 21 (12/03) United States Bankruptcy Court EASTERN DISTRICT OF KENTUCKY ____________ DIVISION IN RE: _______________________________________ _______________________________________ DEBTOR(S) CASE NO. _________ Address _______________________________________ _______________________________________ Chapter ______ Employers Tax Identification (EIN) No(s) [if any]: ______________ Last four digits of Social Security No(s): ________ STATEMENT OF SOCIAL SECURITY NUMBER(S) 1. Name of Debtor (enter Last, First, Middle):_______________________________ (Check the appropriate box and, if applicable, provide the required information.) q Debtor has a Social Security Number and it is: _ _ _-_ _-_ _ _ _ (If more than one, state all.) q Debtor does not have a Social Security Number. 2. Name of Joint Debtor (enter Last, First, Middle):__________________________ (Check the appropriate box and, if applicable, provide the required information.) q Joint Debtor has a Social Security Number and it is: _ _ _-_ _-_ _ _ _ (If more than one, state all.) q Joint Debtor does not have a Social Security Number. 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.