OFFICIAL FORM 21
UNITED STATES BANKRUPTCY COURT EASTERN AND WESTERN DISTRICTS OF ARKANSAS
In re ) ) ) ) Debtor(s) ) ) Address: ) ) ) Last four digits of Social Security No(s): ) all of Employer's Tax Identification No(s) [if any]: ) ) ) ___________________________________________ 1. Name of Debtor:
(Last, First, Middle)
Case No. Chapter
STATEMENT OF SOCIAL SECURITY NUMBER(S)
(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:
(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. ________________________________________
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
Clear Form