Free B21 - Montana

B 21 [12/01/03] Name, Address, Telephone No. & I.D. No.

UNITED STATES BANKRUPTCY COURT
DISTRICT OF MONTANA 400 North Main Street, Butte, MT, 59701 In Re

BANKRUPTCY NO.

Debtor.

STATEMENT OF SOCIAL SECURITY NUMBER
1. Name of Debtor (enter Last, First, Middle): (Check the appropriate box and, if applicable, provide the required information.)

Debtor has a Social Security Number and it is: (If more than one, state all)

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.)

Joint Debtor has a Social Security Number and it is: (If more than one, state all)

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

B 21