UNITED STATES BANKRUPTCY COURT DISTRICT OF NORTH DAKOTA In Re: Case No.___________________ Debtor. ___________________________________ 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 abovereferenced case __________________________________________________(state the dates 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___. ____________________________________________ Debtor (signature) * A separate form must be filed by each Debtor, if appropriate. American LegalNet, Inc. www.FormsWorkflow.com