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UNITED STATES BANKRUPTCY COURT DISTRICT OF ALASKA
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Case No. Chapter

Debtor(s) Address:

STATEMENT OF SOCIAL SECURITY NUMBER(S)

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)

(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. §§ 152 and 3571