Form
B 21 Official Form 21
(12/03)
FORM
21. STATEMENT OF SOCIAL SECURITY NUMBER
[Caption
as in Form 16A.]
1. Name
of Debtor (enter Last, First,Middle):______________________
(Check
the appropriate box and, if applicable, provide the required
information.)
/
/ Debtor has a Social Security Number and it is: _ _ _
- _ _ - _ _ _ _ (If
more than one, state all.)
/
/ Debtor does not have a Social Security Number.
2. Name
of Joint Debtor (enter Last, First, Middle):____________________
(Check
the appropriate box and, if applicable, provide the required
information.)
/
/ 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.
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. §§ 152and
3571.
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