Free Statement of Social Security Number or Individual Taxpayer-Identification Number (ITIN) - All


File Size: 273.2 kB
Pages: 1
Date: November 28, 2007
File Format: PDF
State: All
Category: General Forms
Author: US Courts
Word Count: 279 Words, 2,324 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.uscourts.gov/rules/BK_Forms_1207/B_021_1207f.pdf

Download Statement of Social Security Number or Individual Taxpayer-Identification Number (ITIN) ( 273.2 kB)


Preview Statement of Social Security Number or Individual Taxpayer-Identification Number (ITIN)
B 21 (Official Form 21) (12/07)

UNITED STATES BANKRUPTCY COURT
__________ District Of __________
In re __________________________________________, [Set forth here all names including married, maiden, and trade names used by debtor within last 8 years] Debtor Address __________________________________________ __________________________________________ Last four digits of Social-Security or Individual TaxpayerIdentification (ITIN) No(s).,(if any): ___________________ _________________________________________________ Employer Tax-Identification (EIN) No(s).(if any): _________________________________________________ ) ) ) ) ) ) ) ) ) ) ) ) )

Case No. ______________ Chapter _______________

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 X

_________________________________________________ Signature of Debtor Date _________________________________________________ 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.

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