February 2006 2006 USBC Central District of California UNITED STATES BANKRUPTCY COURT CENTRAL DISTRICT OF CALIFORNIA In re CHAPTER: Debtor(s). CASE NO.: DEBTOR’S CERTIFICATION OF EMPLOYMENT INCOME PURSUANT TO 11 U.S.C. § 521(a)(1)(B)(iv) Please fill out the following blank(s) and check the box next to one of the following statements: , the debtor in this case, declare under penalty I, (Print Name of Debtor) of perjury under the laws of the United States of America that: G I have attached to this certificate copies of my pay stubs, pay advices and/or other proof of employment income for the 60-day period prior to the date of the filing of my bankruptcy petition. (NOTE: the filer is responsible for blacking out the Social Security number on pay stubs prior to filing them.) G I was self-employed for the entire 60-day period prior to the date of the filing of my bankruptcy petition, and received no payment from any other employer. G I was unemployed for the entire 60-day period prior to the date of the filing of my bankruptcy petition. , the debtor in this case, declare under penalty of I, (Print Name of Joint Debtor, if any) perjury under the laws of the United States of America that: G I have attached to this certificate copies of my pay stubs, pay advices and/or other proof of employment income for the 60-day period prior to the date of the filing of my bankruptcy petition. (NOTE: the filer is responsible for blacking out the Social Security number on pay stubs prior to filing them.) G I was self-employed for the entire 60-day period prior to the date of the filing of my bankruptcy petition, and received no payment from any other employer. G I was unemployed for the entire 60-day period prior to the date of the filing of my bankruptcy petition. Date Signature Debtor Date Signature Joint Debtor (if any)