Local Form 121 (Rev: 12/2015) Do not file this form as part of the public case file. This form must be submitted separately and must not be included in the court's public electronic records. Please consult local court procedures for submission requirements. UNITED STATES BANKRUPTCY COURT FOR THE EASTERN DISTRICT OF WISCONSIN In re__________________________________________, Debtor Case No.: _________________________ Chapter: _________________________ STATEMENT OF SOCIAL SECURITY NUMBER(S) 1. Name of Debtor (Last, First, Middle):__________________________________________________ Debtor has a Social Security Number and it is: __________ - _______ - ____________ Debtor has more than one Social Security Number and it is: __________ - _______ - ____________ Debtor does not have a Social Security Number but has an Individual Taxpayer-Identification Number (ITIN), and it is: _______ - ____________________ Debtor does not have either a Social Security Number or an Individual Taxpayer-Identification Number (ITIN). 2. Name of Joint Debtor (Last, First, Middle):__________________________________________________ Joint Debtor has a Social Security Number and it is: __________ - _______ - ____________ Joint Debtor has more than one Social Security Number and it is: __________ - _______ - ____________ Joint Debtor does not have a Social Security Number but has an Individual Taxpayer-Identification Number (ITIN), and it is: _______ - ____________________ Joint Debtor does not have either a Social Security Number or an Individual Taxpayer-Identification Number (ITIN). 3. Name of Spouse if not a Joint Debtor (Last, First, Middle): _____________________________________________ Address ____________________________________________________ ____________________________________________________ Spouse has a Social Security Number and it is: __________ - _______ - ____________ Spouse has more than one Social Security Number and it is: __________ - _______ - ____________ Spouse does not have a Social Security Number but has an Individual Taxpayer-Identification Number (ITIN), and it is: _______ - ____________________ Spouse 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 * * * * Check the appropriate boxes above and provide the required information. Debtor must provide information for spouse if not the Joint Debtor. If Debtor, Joint Debtor, or Spouse (if not Joint Debtor) has more than one Social Security Number, state all. Penalty for making false statement: Fine of up to $250,000.00 or up to 5 years imprisonment or both, pursuant to 18 U.S.C. § § 152 and 3571. American LegalNet, Inc. www.FormsWorkFlow.com