Free Statement of Social Security Number - Pennsylvania

Form B 21 Official Form 21 (12/03)

FORM 21. STATEMENT OF SOCIAL SECURITY NUMBER [Caption as in Form 16A.]

STATEMENT OF SOCIAL SECURITY NUMBER(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.) / /Joint Debtor has a Social Security Number and it is: _ _ _-_ _-_ _ _ _ (If more than one, state all.) / /Joint 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 ______________________________________________ Signature of Joint Debtor Date

X

______________________________________________________________________________ *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.