Free Statement of Social Security Number(s)(or other Individual Taxpayer Identification Number(s) (ITIN(s)) - California

B21 (Official Form 21) (12/07)

USBC, EDCA

UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF CALIFORNIA
In re Case No.:

STATEMENT OF SOCIAL SECURITY NUMBER(S)
Debtor(s).r
(or other Individual Taxpayer Identification Number(s) (ITIN(s))

1. Name of Debtor (enter Last, First, Middle): Check the appropriate box and, if applicable, provide the required information.

G Debtor has a Social Security Number and it is: (If more than one, state all.)

-

-

.

G Debtor does not have a Social Security Number but has an Individual Taxpayer Identification Number (ITIN), and it . is: (If more than one, state all.) G Debtor does not have either a Social Security Number or an Individual Taxpayer Identification Number (ITIN).
2. Name of Joint Debtor (enter Last, First, Middle)r : Check the appropriate box and, if applicable, provide the required information.

G Joint Debtor has a Social Security Number and it is: (If more than one, state all.)

-

-

.

G Joint Debtor does not have a Social Security Number but has an Individual Taxpayer Identification Number (ITIN), and . it is: (If more than one, state all.) G Joint Debtor 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
r

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.