Statement Of Social Security Or Employee Identification Number (Unclaimed Funds)
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Statement Of Social Security Or Employee Identification Number (Unclaimed Funds) Form. This is a Illinois form and can be use in USBC Northern Federal.
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Tags: Statement Of Social Security Or Employee Identification Number (Unclaimed Funds), Illinois Federal, USBC Northern
United States Bankruptcy Court
Northern District of Illinois
Eastern Division
In Re:
)
)
)
)
)
Debtor
Bankruptcy Case No.
Statement of Social Security or Employee Identification Number
Name of claimant:
______________________________
Claimant’s Social Security or EI Number:
______________________________
I declare under penalty of perjury that the foregoing is true and correct.
______________________________
Signature of Claimant
Date
______________________________________________________________________________
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.
11-19-03
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