Free Statement of Social Security - Official Form 21 (*) - Illinois

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):_______________________________ (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 (Last, First, Middle):___________________________ (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 /s/ ______________________________________________ Signature of Debtor Date X ______________________________________________ /s/ 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.