Statement Of Social Security Number(s)
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Statement Of Social Security Number(s) Form. This is a Arkansas form and can be use in USBC Eastern And Western Federal.
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Tags: Statement Of Social Security Number(s), 21, Arkansas Federal, USBC Eastern And Western
OFFICIAL FORM 21
UNITED STATES BANKRUPTCY COURT
EASTERN AND WESTERN DISTRICTS OF ARKANSAS
In re )
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Debtor(s)
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Address:
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Last four digits of Social Security No(s):
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all of Employer’s Tax Identification No(s) [if any]:
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___________________________________________
Case No.
Chapter
STATEMENT OF SOCIAL
SECURITY NUMBER(S)
1. Name of Debtor:
(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:
(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.
________________________________________
____________________
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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