_____________________________________________________________________________ UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF WYOMING ______________________________________________________________________________ _ In re: Case No. __________ ___________________________ ___________________________ (INSERT NAME OF DEBTOR(S)) Debtor(s). Chapter ___________ ______________________________________________________________________________ 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 above-referenced case _______________________ (state the dates that you were not employed); _____ b) I was employed during the period immediately preceding the filing of the above-referenced 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; _____ d) Other (Please Explain )__________________________________________ I declare under penalty of perjury that the foregoing statement is true and correct. Dated this _____ day of _____________, 200__. ________________________________ (Signature of Debtor) Debtor American LegalNet, Inc. www.FormsWorkflow.com * A separate form must be filed by each Debtor Certificate of Service I certify that I served true and correct copies of the foregoing declaration by mailing a copy to each the following on this _____ day of ______________, 200__: Trustee Assigned to the Case (Trustee’s Address) United States Trustee American LegalNet, Inc. www.FormsWorkflow.com