Free Statement of S.S. # Official Form B21 - New Hampshire

Form B21
(12/01/03)

UNITED STATES BANKRUPTCY COURT DISTRICT OF NEW HAMPSHIRE
Bk. No. Chapter Debtor(s)

In re:

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.)

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2.

Debtor has a Social Security Number and it is: ______-______-_________ Debtor does not have a Social Security Number.

Name of Joint Debtor (enter Last, First, Middle): __________________________________________________________________ (Check the appropriate box and, if applicable, provide the required information.)

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Joint Debtor has a Social Security Number and it is: _____-_____-_______ Joint Debtor does not have a Social Security Number.

I declare under penalty of perjury that the foregoing social security number 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. §§ 152 and 3751.