United States Bankruptcy Court Northern District of Illinois Eastern Division
In Re: ) ) ) ) ) Bankruptcy Case No.
Debtor
Statement of Social Security or Employee Identification Number
Name of claimant: Claimant's Social Security or EI Number:
______________________________ ______________________________
I declare under penalty of perjury that the foregoing is true and correct.
______________________________ Signature of Claimant Date
______________________________________________________________________________
Penalty for making a false statement: Fine of up to $250,000 or up to 5 years imprisonment or both. 18 U.S.C. ยงยง 152 and 3571.
11-19-03