Free Statement of Social Security Number Form - Arkansas


File Size: 66.0 kB
Pages: 1
Date: February 25, 2005
File Format: PDF
State: Arkansas
Category: Bankruptcy
Author: tammy
Word Count: 186 Words, 1,312 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.arb.uscourts.gov/forms/officialform21.pdf

Download Statement of Social Security Number Form ( 66.0 kB)


Preview Statement of Social Security Number Form
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
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