Statement Of Social Security Number (California Southern District) {B21}

B 21 [07/08/13] Name, Address, Telephone No. & I.D. No. SOUTHERN DISTRICT OF CALIFORNIA 325 West F Street, San Diego, California 92101-6991 In Re UNITED STATES BANKRUPTCY COURT BANKRUPTCY NO. Debtor. STATEMENT OF SOCIAL SECURITY NUMBER(S) (or other Individual Taxpayer-Identification Number(s) (ITIN(s)) 1. Name of Debtor (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 but has an Individual Taxpayer-Identification Number (ITIN), and it is: (If more than one, state all) Debtor does not have either a Social Security Number or an Individual Taxpayer-Identification Number (ITIN). 2. Name of Joint Debtor (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 but has an Individual Taxpayer-Identification Number (ITIN), and it is: (If more than one, state all) Joint Debtor 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. This form is not part of the public case file. This form must be submitted separately and is not included in the court's public electronic records. Please consult local court for submission requirement. 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. §§ 152 and 3571. B 21 American LegalNet, Inc. www.FormsWorkFlow.com