Free Payment Advices Coversheet - Minnesota

UNITED STATES BANKRUPTCY COURT DISTRICT OF MINNESOTA IN RE: Case No.

STATEMENT UNDER PENALTY OF PERJURY RE: PAYMENT ADVICES DUE PURSUANT TO 11 U.S.C. § 521(a)(1)(B)(iv) Debtor has attached to this statement 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. Debtor has not filed copies of payment advices or other evidence of payment received within 60 days before the date of the filing of the petition from any employer because: Debtor was not employed during the 60 days preceding the filing of the petition; Debtor was employed for only a portion of the 60 days preceding the filing of the petition. Please specify period during which debtor was unemployed: Debtor was self-employed during the 60 days preceding the filing of the petition; Debtor received only unemployment, veteran's benefits, social security, disability or other retirement income during the 60 days preceding the filing of the petition; or Other (please explain):

I declare under penalty of perjury that I have read this Statement and it is true to the best of my knowledge, information and belief. Signature of Debtor: Date:

************************************************************ Joint Debtor has attached to this statement 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. Joint Debtor has not filed copies of payment advices or other evidence of payment received within 60 days before the date of the filing of the petition from any employer because: Joint Debtor was not employed during the 60 days preceding the filing of the petition; Joint Debtor was employed for only a portion of the 60 days preceding the filing of the petition. Please specify period during which debtor was unemployed: Joint Debtor was self-employed during the 60 days preceding the filing of the petition; Joint Debtor received only unemployment, veteran's benefits, social security, disability or other retirement income during the 60 days preceding the filing of the petition; or Other (please explain):

I declare under penalty of perjury that I have read this Statement and it is true to the best of my knowledge, information and belief. Signature of Joint Debtor: Date: