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B 21 (Official Form 21) (12/07)

UNITED STATES BANKRUPTCY COURT
District District Of __________ __________ of New Mexico
In re __________________________________________, [Set forth here all names including married, maiden, and trade names used by debtor within last 8 years] Debtor Address __________________________________________ __________________________________________ Last four digits of Social-Security or Individual TaxpayerIdentification (ITIN) No(s).,(if any): ___________________

) ) ) ) ) Case No. ______________ ) ) Chapter _______________ ) )
)

_________________________________________________ ) ) Employer Tax-Identification (EIN) No(s).(if any): _________________________________________________ ) AMENDED 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.) G Debtor has a Social-Security Number and it is: _____________ (If more than one, state all.) G 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.) G 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.) G Joint Debtor has a Social-Security Number and it is: ____________ (If more than one, state all.) G 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.) G 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. 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.

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