Free Statement of SSNs - Fillable (Official Form) - Michigan

Attorney/Debtor Name, Address, Phone, Fax, E-mail:

For Court use only

NOT TO BE FILED
UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF MICHIGAN
In re: Case No. Chapter

Select Chapter
Debtor(s)

STATEMENT OF SOCIAL SECURITY NUMBERS(S)

1.

Name of Debtor (enter 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 (enter 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.

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

X ________________________________________ ________________ Signature of 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. B21 12/03