United States Bankruptcy Court Eastern District of Missouri Form B21 Official Form 21 (12/07) FORM 21. STATEMENT OF SOCIAL SECURITY NUMBER OR INDIVIDUAL TAXPAYER-IDENTIFICATION NUMBER (ITIN) In re (name(s) of debtor(s)) Case No. year-number-judge Chapter STATEMENT OF SOCIAL SECURITY NUMBER(S) (or other Individual Taxpayer-Identification Number(s) (ITIN(s))) 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 Taxpayer-Identification Number (ITIN), and it is: __________________. (If more than one, state all) Debtor does not have either 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 Taxpayer-Identification Number (ITIN), and it is: __________________. (If more than one, state all) 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. X ___________________________________________________ Signature of Debtor Date X ___________________________________________________ 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. American LegalNet, Inc. www.FormsWorkFlow.com