Free Form B21-Statement of Social Security Number(s) - Alabama

Form B 21 Official Form 21 (12/03)

UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF ALABAMA
IN RE:__________________________________ Debtor(s) CASE NO.___________________

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

X__________________________________
Signature of Joint Debtor

_____________
Date

_____________________________________________________________________________________________________________________________________________________________________________________________________ ______

*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.