Form B21 (Official Form 21) - (12/07) 2007 USBC, Central District of California UNITED STATES BANKRUPTCY COURT CENTRAL DISTRICT OF CALIFORNIA In re (set forth here all names including married, maiden, and trade names used by the debtor within last 8 years): FOR COURT USE ONLY Debtor. Address: Case No.: Chapter: Last four digits of Social Security Number(s): STATEMENT OF SOCIAL-SECURITY NUMBER(S) (OR OTHER INDIVIDUAL TAXPAYER-IDENTIFICATION NUMBER (ITIN)) Complete Employer’s Tax Identification Number(s) (if any): 1. Name of Debtor (enter 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 (enter 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. 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.