UNITED STATES BANKRUPTCY COURT

FOR THE EASTERN DISTRICT OF MISSOURI

__________________ DIVISION

In re:	)

______________________	)	Case No.________________

)	Chapter ____________

Debtor(s).	)

Statement Under Penalty of Perjury Concerning Payment Advices and Tax Returns

Pursuant to 11 U.S.C. § 521 (a)(1)(B)(iv), 11 U.S.C. § 521(e)(2)(A), the Local Rules of Bankruptcy Procedure, and the Federal Rules of Bankruptcy Procedure,

I, ___________________________________ (Debtor's Name), state as follows:

______ a)	I hereby provide to the Trustee all payment advices received in the 60 days prior to filing the petition. The payment advices are attached to this statement;

______ b)	I was not employed during the period immediately preceding the filing of the above-referenced case _____________________ (state the dates that you were not employed);

______ c)	I was employed during the period immediately preceding the filing of the above-
referenced case but did not receive any payment advices or other evidence of payment from my employer within 60 days before the date of the filing of the petition. I believe my gross income during the 60 day period preceding the filing of this case was: $__________________;

______ d)	I was self-employed and did not receive any evidence of payment from an employer. I believe my gross income during the 60 day period preceding the filing of this case was: $___________________;

______ e)	I received payment advices during the 60 days prior to the filing of this bankruptcy case but have been unable to locate the documents. I believe my gross income during the 60 day period preceding the filing of this case was:

$____________________;

______ f)	I received payment advices during the 60 days prior to the filing of this bankruptcy case but have been unable to locate one or more advices from all employers. I believe my gross income during the 60 days prior to the filing of this case was:

Employer #1 _________________________	$___________________

Employer #2 _________________________	$ ___________________

Employer #3 _________________________	$___________________

______ g)	I am not required to file a tax return for the most recent tax year ending immediately before the filing of the case because________________________________.

______ h)	The last tax returns that I filed were for the year _____________________.

______ i)	I otherwise do not have the most recently filed tax returns because ________________________________.

______ j)	Other (Please Explain) ______________________________________________.

I declare under penalty of perjury that the foregoing statement is true and correct.

Dated this _______ day of _________________ 20__.

___________________________________ (Signature of Debtor)

Debtor

10/2020

* A separate form must be prepared by each Debtor in a joint case. This document, the payment advices, or another verified statement must be provided to the Trustee prior to the § 341 meeting of creditors as specified in the Local Rules of Bankruptcy Procedure.