Free Form 21 - Statement of Social Security Number(s) - Wisconsin


File Size: 234.6 kB
Pages: 1
Date: January 15, 2008
File Format: PDF
State: Wisconsin
Category: Bankruptcy
Author: Becky
Word Count: 274 Words, 2,270 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.wiw.uscourts.gov/bankruptcy/fillable_forms/Form21.pdf

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B21 (Official Form 21) (12/07)

STATEMENT OF SOCIAL-SECURITY NUMBER OR INDIVIDUAL TAXPAYER-IDENTIFICATION NUMBER (ITIN)
[Caption as in Form 16A] STATEMENT OF SOCIAL-SECURITY NUMBER(S) (or other Individual Taxpayer-Identification Number(s) (ITIN(s)))

1. Name of Debtor (Last, First, Middle):_________________________________ Debtor has a Social-Security Number and it is:__________________________ Debtor does not have a Social-Security Number but has an Individual Taxpayer-Identification Number (ITIN), and it is:__________________________ Debtor does not have either a Social-Security Number or an Individual Taxpayer-Identification Number (ITIN). 2. Name of Joint Debtor (Last, First, Middle):_________________________________ Joint Debtor has a Social-Security Number and it is:__________________________ Joint Debtor does not have a Social-Security Number but has an Individual TaxpayerIdentification Number (ITIN), and it is:__________________________ Joint Debtor does not have either a Social-Security Number or an Individual TaxpayerIdentification Number (ITIN). 3. Name of Spouse if not a Joint Debtor (Last, First, Middle):__________________________________ Address: ____________________________________ ____________________________________ Spouse has a Social-Security Number and it is:__________________________ Spouse does not have a Social-Security Number but has an Individual Taxpayer-Identification Number (ITIN), and it is:__________________________ Spouse does not have either a Social-Security Number or an Individual Taxpayer-Identification Number (ITIN) I declare under penalty of perjury that the foregoing is true and correct. X _____________________________________________________________ Signature of Debtor Date X _____________________________________________________________ Signature of Joint Debtor Date

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Check the appropriate boxes above and provide the required information. Joint debtors must provide information for both spouses. Debtor must provide information for non-filing spouse. If Debtor, Joint Debtor or Non-Filing Spouse has more than one Social Security Number, state all. Penalty for making a false statement: Fine of up to $250,000 or up to 5 years imprisonment or both. 18 U.S.C. ยงยง 152 and 3571.