Free LBF-1 - Indiana

LBF-1 (rev. 10/01)

UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF INDIANA DIVISION

IN THE MATTER OF:

Debtor(s)

) ) ) )

CASE NO. Chapter

STATEMENT CONCERNING STATUS OF FILING OF TAX RETURNS AND TAX REVIEW PROCEEDINGS

The undersigned debtor(s) in the above-designated case, do hereby state (check, and complete as applicable, box 1, box 2 or box 3, and box 4 or box 5): Status of Filing of Tax Returns 1. That each debtor had filed, prior to the commencement of this case, all federal, state and local tax returns for every tax period ending on or before the date of the filing of the above designated case.

OR 2. That the following required federal, state, or local tax returns, for a tax period ending on or before the filing of the above-designated case, have not been filed by the debtor(s) prior to the filing of the above designated case:

Taxing Au thority (e.g,. IRS; State of Indiana; County; M unicip ality; other [designate])

Type of Tax

Tax Reporting Period

OR 3. No return required to be filed for the following year(s): because

And

Status of Tax Review Proceedings 4. The debtor(s) is/are unaware of any administrative or judicial proceedings, including audits, with respect to any federal, state, or local tax returns filed by the debtor(s) prior to the filing of the above-designated case, or with respect to any potential tax obligations of the debtor(s) for any tax period ending prior to the filing of the above designated case. OR 5. The following tax returns filed by the debtor(s) prior to the filing of the abovedesignated case, or the following potential tax obligations of the debtor(s) for a tax period ending prior to the filing of the above-designated case, are known by the debtor(s) to be the subject of administrative or judicial proceedings, including audits:
Nature of Adm inistrative/Judicial Proceeding (If ju dicial proceeding, state case nam and num and e ber court of record.)

Taxing Authority

Type of Tax

Tax Reporting Period

UNSWORN DECLARATION UNDER PENALTY OF PERJURY FOR INDIVIDUAL (To be signed by both spouses when joint petition is filed.) , (if joint petition is filed) and, declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge, information, and belief. Executed on: Signature: I,

UNSWORN DECLARATION UNDER PENALTY OF PERJURY ON BEHALF OF CORPORATION OR PARTNERSHIP I, , (the president, other officer, or an authorized agent of the corporation) (a member or an authorized agent of the partnership) named as debtor in this case, declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge, information, and belief.

Executed on:

Signature:

(Note: If explanation or additional information is deemed necessary, attach on separate page. Any attachment is also subject to the foregoing Unsworn Declaration.) CERTIFICATE OF SERVICE This is to certify under penalty of perjury that on the , 20 , I deposited in the United States Mail at day of , a copy of the

foregoing Certificate of Status of Filing of Tax Returns and Tax Review Proceedings properly addressed to:

A. (If box 2 or box 4 applicable to Internal Revenue Service) Small Business/Self-Employed Compliance Services Insolvency Territory 7 P.O. Box 44985 -- STOP SB 380 Indianapolis, IN 46244 and to Office of the United States Attorney for the Northern District of Indiana: 1001 Main Street, Suite A Dyer, Indiana 46311

204 S. Main Street South Bend, IN 46601

3128 Federal Building 1300 S. Harrison Street Fort Wayne, IN 46802

B. (If box 2 or box 4 applicable to State of Indiana) Indiana Department of Revenue 100 N. Senate Indianapolis, IN 46206

C. (If box 2 or box 4 applicable to county, municipal, or other taxing authority, including a state other than Indiana.

D.

and to United States trustee 555 One Michiana Square Building 100 East Wayne Street South Bend, IN 46601 and to

E.

Chapter

Trustee