Free STATEMENT OF SOCIAL SECURITY NUMBER(S) - Virginia

B21 (Official Form 21) (12/07)

UNITED STATES BANKRUPTCY COURT Eastern District of Virginia
___________________ Division

In re: Bankruptcy Case No.: Debtor(s)*

STATEMENT OF SOCIAL SECURITY NUMBER(S) OR INDIVIDUAL TAXPAYER-IDENTIFICATION NUMBER (ITIN)
1. Name of Debtor (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 but has an Individual Taxpayer-Identification Number (ITIN), and it is: ___________________. (If more than one, state all.) Debtor does not have either a Social-Security Number or an Individual TaxpayerIdentificationNumber (ITIN). 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 but has an Individual Taxpayer-Identification Number (ITIN) and it is: ________________.. (If more than one, state all.) Joint Debtor does not have either a Social-Security Number or an Individual TaxpayerIdentificationNumber (ITIN).

I declare under penalty of perjury that the foregoing is true and correct. X ______________________________________________ Signature of Debtor Date X ______________________________________________ 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 3571.

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