T.L.B.F. 1007-1 UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF COLORADO In re: Case No. __________ ___________________________ ___________________________ (INSERT NAME(S) OF DEBTOR(S)) Address____________________ ___________________________ Last 4 digits of SSN and/or EIN: ___________________________ Debtor(s). Chapter ___________ Statement Under Penalty of Perjury Concerning Payment Advices Due Pursuant to 11 U.S.C. §521(a)(1)(B)(iv) I*, ______________(Debtor's Name), state as follows: I did not file with the Court copies of all payment advices or other evidence of payment received within 60 days before the date of the filing of the petition from any employer because: _____ a) I was not employed during the period immediately preceding the filing of the above-referenced case _______________________ (state the dates that you were not employed); _____ b) I was employed during the period immediately preceding the filing of the abovereferenced case but did not receive any payment advices or other evidence of payment from my employer within 60 days before the date of the filing of the petition; _____ c) I am self-employed and do not receive any evidence of payment from an employer; _____ d) Other (Please Explain )__________________________________________ I declare under penalty of perjury that the foregoing statement is true and correct. Dated this _____ day of _____________, 200__. ________________________________ (Signature of Debtor) Debtor * A separate form must be filed by each Debtor 1007-1 form American LegalNet, Inc. www.FormsWorkflow.com Certificate of Service I certify that I served true and correct copies of the foregoing declaration by mailing a copy to each the following on this _____ day of ______________, 200__: Trustee Assigned to the Case (Trustee’s Address) United States Trustee _____________________ Signed 1007-1 form American LegalNet, Inc. www.FormsWorkflow.com