Form B 21 Official Form 21 - MN (12/07) UNITED STATES BANKRUPTCY COURT DISTRICT OF MINNESOTA In re: Case No. _____________ Debtor(s). STATEMENT OF SOCIAL SECURITY NUMBER OR INDIVIDUAL TAXPAYER-IDENTIFICATION NUMBER (ITIN) 1. Name of Debtor (enter Last, First, Middle): ____________________________________ (Check the appropriate box and, if applicable, provide the required information.) G G G 2. Debtor has a Social Security Number and it is: _ _ _ - _ _ - _ _ _ _ (If more than one, state all.) Debtor does not have a Social Security Number, but has an Individual TaxpayerIdentification Number (ITIN) and it is: ____________________ (If more than one, state all) Debtor does not have a Social Security Number or an Individual Taxpayer-Identification Number (ITIN). Name of Joint Debtor (enter Last, First, Middle): ________________________________ (Check the appropriate box and, if applicable, provide the required information.) G G G Joint Debtor has a Social Security Number and it is: _ _ _ - _ _ - _ _ _ _ (If more than one, state all.) Joint Debtor does not have a Social Security Number, but has an Individual TaxpayerIdentification Number (ITIN) and it is: ____________________ (If more than one, state all) Joint Debtor does not have a Social Security Number or an Individual TaxpayerIdentification Number (ITIN). I declare under penalty of perjury that the foregoing is true and correct. X __________________________________ Signature of Debtor ___________________ Date X___________________________________ Signature of Joint Debtor ___________________ Date THIS STATEMENT MUST BE SUBMITTED IN PAPER FORM WITH: (1) PETITIONS FILED ON DISKETTE BY ATTORNEYS; AND (2) PETITIONS FILED IN PAPER FORM BY PRO SE DEBTORS. DO NOT ELECTRONICALLY FILE THIS DOCUMENT. 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. American LegalNet, Inc. www.FormsWorkflow.com