Free Local Form # 12 revised 2-28-06 - Pennsylvania

LOCAL BANKRUPTCY FORM NO. 12 IN THE UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF PENNSYLVANIA

IN RE Debtor(s)

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Bankruptcy No. Chapter Related to Document No.

NOTIFICATION OF DEBTOR'S SOCIAL SECURITY NUMBER Name of employer or other party subject to wage attachment: Debtor's name: Debtor's nine digit social security number: Debtors address: Debtors phone number: This notification is accompanied by a Wage Attachment Order issued by a United States Bankruptcy Judge regarding attachment of the debtor's wages. The debtor's social security number is being provided to assist in complying with the court order. -

Date: Signature: Attorney for Debtor(s) [or pro se Debtor(s)] (Typed Name) (Address) (Phone No.) List Bar I.D. and State of Admission