UNITED STATES BANKRUPTCY COURT FOR THE NORTHERN DISTRICT OF WEST VIRGINIA IN RE: Debtor(s). § § § § § § BK NO. 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 that I did not file copies of all payment advices or other evidence of payment received within 60 days before the date of the filing of the petition, by me from any employer because: _____ (1) I was not employed during the period immediately preceding the filing of the above-referenced case _______________________ (state the dates that you were not employed); _____ (2) 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 filing of the petition; _____ (3) I am self employed and do not receive any evidence of payment; _____ (4) Other (please explain) _______________________________________. I declare under penalty of perjury that I have read the foregoing statements and that they are true and accurate to the best of my knowledge, information and belief. Dated this _____ day of __________, 200__. __________________________________________ (Signature of Debtor) Debtor *a separate form must be filed for each Debtor. American LegalNet, Inc. www.FormsWorkflow.com