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UNITED STATES BANKRUPTCY COURT FOR THE EASTERN DISTRICT OF MISSOURI __________________ DIVISION In re: ______________________ Debtor(s). ) ) ) )

Case No.________________ Chapter ____________

Statement Under Penalty of Perjury Concerning Payment Advices and Tax Returns Pursuant to 11 U.S.C. § 521 (a)(1)(B)(iv), 11 U.S.C. § 521(e)(2)(A), the Local Rules of Bankruptcy Procedure, the Federal Rules of Bankruptcy Procedure, and this Court's Order Implementing Interim Procedures Under the Bankruptcy Abuse Prevention and Consumer Protection Act of the 2005 as applicable, I, ___________________________________ (Debtor's Name), state as follows: ______ a) I hereby provide to the Trustee all payment advices received in the 60 days prior to filing the petition. The payment advices are attached to this statement; I was not employed during the period immediately preceding the filing of the abovereferenced case _____________________ (state the dates that you were not employed); I was employed during the period immediately preceding the filing of the abovereferenced 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. I believe my gross income during the 60 day period preceding the filing of this case was: $__________________; I was self-employed and did not receive any evidence of payment from an employer. I believe my gross income during the 60 day period preceding the filing of this case was: $___________________; I received payment advices during the 60 days prior to the filing of this bankruptcy case but have been unable to locate the documents. I believe my gross income during the 60 day period preceding the filing of this case was: $____________________; I received payment advices during the 60 days prior to the filing of this bankruptcy case but have been unable to locate one or more advices from all employers. I believe my gross income during the 60 days prior to the filing of this case was: Employer #1 _________________________ $___________________ Employer #2 _________________________ $ ___________________ Employer #3 _________________________ $___________________ I am not required to file a tax return for the most recent tax year ending immediately before the filing of the case because________________________________. The last tax returns that I filed were for the year _____________________.

______ b)

______ c)

______ d)

______ e)

______ f)

______ g)

______ h)

______ i)

I otherwise do not have the most recently filed tax returns because ________________________________. Other (Please Explain) ______________________________________________.

______ j)

I declare under penalty of perjury that the foregoing statement is true and correct. Dated this _______ day of _________________ 200__.

___________________________________ (Signature of Debtor) Debtor

* A separate form must be prepared by each Debtor in a joint case. This document, the payment advices, or another verified statement must be provided to the Trustee prior to the § 341 meeting of creditors as specified in the Local Rules of Bankruptcy Procedure and/or the Court's Implementation Order as applicable.