Official Form 121 Statement About Your Social Security Numbers
United States Bankruptcy Court for the:
__________ District of __________
Case number (If known): _________________________
Fill in this information to identify your case:
Official Form 121
Statement About Your Social Security Numbers 12/15
Use this form to tell the court about any Social Security or federal Individual Taxpayer Identification numbers you have used. 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.
To protect your privacy, the court will not make this form available to the public. You should not include a full Social Security Number or
Individual Taxpayer Number on any other document filed with the court. The court will make only the last four digits of your numbers known
to the public. However, the full numbers will be available to your creditors, the U.S. Trustee or bankruptcy administrator, and the trustee
assigned to your case.
Making a false statement, concealing property, or obtaining money or property by fraud in connection with a bankruptcy case can result in
fines up to $250,000, or imprisonment for up to 20 years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571.
Part 1: Tell the Court About Yourself and Your spouse if Your Spouse is Filing With You
For Debtor 1:
For Debtor 2 (Only If Spouse Is Filing):
1. Your name
_________________________________________________
First name
_________________________________________________
Middle name
_________________________________________________
Last name
_________________________________________________
First name
_________________________________________________
Middle name
_________________________________________________
Last name
Part 2: Tell the Court About all of Your Social Security or Federal Individual Taxpayer Identification Numbers
2. All Social Security
Numbers you have
used
__ __ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __ __
You do not have a Social Security number.
__ __ __ __ __
__ __ __ __
__ __ __ __ __
__ __ __ __
You do not have a Social Security number.
3. All federal Individual
Taxpayer
Identification
Numbers (ITIN) you
have used
9 __ __ __ __ __ __ __ __
9 __ __ __ __ __ __ __ __
You do not have an ITIN.
9 __ __ __ __ __ __ __ __
9 __ __ __ __ __ __ __ __
You do not have an ITIN.
Part 3: Sign Below
Under penalty of perjury, I declare that the information
I have provided in this form is true and correct.
_______________________________________
Signature of Debtor 1
Date _________________
MM / DD / YYYY
Under penalty of perjury, I declare that the information
I have provided in this form is true and correct.
_______________________________________
Signature of Debtor 2
Date _________________
MM / DD / YYYY
__________ District of __________
