Free Payment Advice Form - O:521 - New York

UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF NEW YORK In re
[Set forth here all names including married, maiden, and trade names used by debtor within last 8 years.]

Debtor

Employer's Tax Identification No(s). [if any] Last four digits of Social Security No(s): For Debtor: Payment advices are attached

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Case No. Chapter

Payment advices are not attached because debtor had no income from any employer during the 60 days prior to filing the bankruptcy petition. Payment advices are not attached because debtor: receives disability payments is unemployed and does not receive unemployment compensation receives Social Security payments receives a pension does not work outside the home is self employed other, please explain Schedule I, Line 1 Income Occupation as listed on Schedule I For Joint Debtor, if applicable: Payment advices are attached Payment advices are not attached because debtor had no income from any employer during the 60 days prior to filing the bankruptcy petition. Payment advices are not attached because debtor: receives disability payments is unemployed and does not receive unemployment compensation receives Social Security payments receives a pension does not work outside the home is self employed other, please explain Schedule I, Line 1 Income Occupation as listed on Schedule I I declare under penalty of perjury that I have read this Payment Advices Cover Sheet and the attached payment advices, consisting of ___ sheets, and that they are true and correct to the best of my knowledge, information and belief. Signature of Debtor: Signature of Joint Debtor: :
O:§521C(03/02/2006)

Date: Date: