UNITED STATES BANKRUPTCY COURT
DISTRICT OF MINNESOTA
In re: Case No.
Debtor(s).
STATEMENT UNDER PENALTY OF PERJURY RE:
PAYMENT ADVICE DUE PURSUANT TO 11 U.S.C. § 521(a)(1)(B)(iv)
‘
Debtor 1 has attached to this statement copies of all payment advices or other evidence of payment received
within 60 days before the date of the petition from any employer.
‘ Debtor 1 has not filed copies of payment advices or other evidence of payment received within 60 days before the
date of the filing of the petition from any employer because:
‘ Debtor 1 was not employed during the 60 days preceding the filing of the petition;
‘ Debtor 1 was employed for only a portion of the 60 days preceding the filing of the petition. Please specify
period during which debtor was unemployed:
‘ Debtor 1 was self-employed during the 60 days preceding the filing of the petition;
‘ Debtor 1 received only unemployment, veteran’s benefits, social security, disability or other retirement
income during the 60 days preceding the filing of the petition; or
‘ Other (please explain):
I declare under penalty of perjury that I have read this Statement and it is true to the best of my knowledge, information
and belief.
Signature of Debtor 1:
Date:
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‘ Debtor 2 has attached to this statement copies of all payment advices or other evidence of payment received
within 60 days before the date of the petition from any employer.
‘ Debtor 2 has not filed copies of payment advices or other evidence of payment received within 60 days before the
date of the filing of the petition from any employer because:
‘ Debtor 2 was not employed during the 60 days preceding the filing of the petition;
‘ Debtor 2 was employed for only a portion of the 60 days preceding the filing of the petition. Please specify
period during which debtor was unemployed:
‘ Debtor 2 was self-employed during the 60 days preceding the filing of the petition;
‘ Debtor 2 received only unemployment, veteran’s benefits, social security, disability or other retirement
income during the 60 days preceding the filing of the petition; or
‘ Other (please explain):
I declare under penalty of perjury that I have read this Statement and it is true to the best of my knowledge, information
and belief.
Signature of Debtor 2:
Date:
***IMPORTANT NOTE: Please make sure all SOCIAL SECURITY numbers, routing numbers and account
numbers are redacted before filing. If the income records include the year to date amounts, you are only required to
submit the first and last pay stubs from the previous 60 days.
