Official Form 121 "Statement About Your Social Security Numbers"

What Is Official Form 121?

This is a legal form that was released by the United States Bankruptcy Court on December 1, 2015 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2015;
  • The latest available edition released by the United States Bankruptcy Court;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Official Form 121 by clicking the link below or browse more documents and templates provided by the United States Bankruptcy Court.

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Download Official Form 121 "Statement About Your Social Security Numbers"

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Fill in this information to identify your case:
United States Bankruptcy Court for the:
District of __________
__________ District of __________
__________
Case number
_________________________
(If known):
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
First name
_________________________________________________
_________________________________________________
Middle name
Middle name
_________________________________________________
_________________________________________________
Last 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
__ __ __
__ __
__ __ __ __
__ __ __
__ __ __ __ __ __
ou do not have a Social Security number.
You do not have a Social Security number.
Y
3. All federal Individual
9
9
__ __
__ __
__ __ __ __
__ __
__ __
__ __ __ __
Taxpayer
Identification
Numbers (ITIN) you
9
9
__ __
__ __
__ __ __ __
__ __
__ __
__ __ __ __
have used
You do not have an ITIN.
You do not have an ITIN.
Part 3:
Sign Below
Under penalty of perjury, I declare that the information
Under penalty of perjury, I declare that the information
I have provided in this form is true and correct.
I have provided in this form is true and correct.
_______________________________________
_______________________________________
Signature of Debtor 1
Signature of Debtor 2
Date _________________
Date _________________
MM / DD / YYYY
MM / DD / YYYY
Official Form 121
Statement About Your Social Security Numbers
Print
Save As...
Reset
Fill in this information to identify your case:
United States Bankruptcy Court for the:
District of __________
__________ District of __________
__________
Case number
_________________________
(If known):
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
First name
_________________________________________________
_________________________________________________
Middle name
Middle name
_________________________________________________
_________________________________________________
Last 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
__ __ __
__ __
__ __ __ __
__ __ __
__ __ __ __ __ __
ou do not have a Social Security number.
You do not have a Social Security number.
Y
3. All federal Individual
9
9
__ __
__ __
__ __ __ __
__ __
__ __
__ __ __ __
Taxpayer
Identification
Numbers (ITIN) you
9
9
__ __
__ __
__ __ __ __
__ __
__ __
__ __ __ __
have used
You do not have an ITIN.
You do not have an ITIN.
Part 3:
Sign Below
Under penalty of perjury, I declare that the information
Under penalty of perjury, I declare that the information
I have provided in this form is true and correct.
I have provided in this form is true and correct.
_______________________________________
_______________________________________
Signature of Debtor 1
Signature of Debtor 2
Date _________________
Date _________________
MM / DD / YYYY
MM / DD / YYYY
Official Form 121
Statement About Your Social Security Numbers
Print
Save As...
Reset