UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF GEORGIA ______________DIVISION IN RE: Debtor : : : : : Case No. _______________ Chapter _______________ STATEMENT REGARDING PAY STUBS (11 U.S.C. §521(a)(1)) I, the undersigned debtor, hereby certify that during the 60 day period preceding the filing of my bankruptcy petition in this case, I did not receive pay stubs from an employer because: 9 I am unemployed; or 9 I am self-employed; or 9 My employer did not provide pay stubs. 9 Other _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Dated:_____________________ ________________________________ Debtor American LegalNet, Inc. www.FormsWorkflow.com