Free Statement Under Penalty of Perjury Concerning Payment Advices Due - Louisiana

05/06

United States Bankruptcy Court Western District of Louisiana
In re:
Debtor(s)

Case No.:

Chapter:

Statement Under Penalty of Perjury Concerning Payment Advices Due Pursuant to 11 USC §521(A)(1)(B)(iv)
I *, __________________________________, state as follows:
Debtor's Name

I did not file with the Court copies of all payment advices or other evidence of payment received within 60 days before the date of the filing of the petition from any employer due to one of the following: ________ (a) I was not employed during the period immediately preceding the filing of the above-referenced case _________________________________________ ;
Please enter dates not employed.

________ (b) I was employed during the period immediately preceding the filing of the above-referenced case but did not receive any payment advices or other evidence of payment from my employer within 60 days before the date of the filing of the petition; ________ (c) I am self-employed and do not receive any evidence of payment; ________ (d) Other (Please Explain, i.e. Retired, etc.) _____________________________ ____________________________________________________________ I declare under penalty of perjury that I have read the foregoing statement and that it is true and correct to the best of my knowledge, information, and belief.

Dated: ___________________

__________________________________ Signature of Debtor

* A separate form must be filed by each Debtor.