CACB — Declaration by Debtor(s) as to Whether Income Was Received From an Employer Within 60 Days of (F1002-1.EMPINCOMEDEC)

Source: https://www.cacb.uscourts.gov/sites/cacb/files/documents/forms/F1002-1.EMPINCOMEDEC.pdf

Attorney or Party Name, Address, Telephone & FAX FOR COURT USE ONLY Nos., State Bar No. & Email Address

Debtor(s) appearing without an attorney Attorney for Debtor(s)

UNITED STATES BANKRUPTCY COURT

CENTRAL DISTRICT OF CALIFORNIA - SELECT DIVISION DIVISION

In re: CASE NO.: CHAPTER:

DECLARATION BY DEBTOR(S)
AS TO WHETHER INCOME WAS RECEIVED
FROM AN EMPLOYER WITHIN 60 DAYS OF
THE PETITION DATE
[11 U.S.C. § 521(a)(1)(B)(iv)]

[No hearing required] Debtor(s).

Debtor(s) provides the following declaration(s) as to whether income was received from an employer within 60 days of the Debtor(s) filing this bankruptcy case (Petition Date), as required by 11 U.S.C. § 521(a)(1)(B)(iv):

Declaration of Debtor 1

1. I am Debtor 1 in this case, and I declare under penalty of perjury that the following information is true and correct:

   During the 60-day period before the Petition Date (Check only ONE box below): I was paid by an employer. Attached are copies of all statements of earnings, pay stubs, or other proof of employment income I received from my employer during this 60-day period. (If the Debtor’s social security number or bank account is on a pay stub or other proof of income, the Debtor must cross out (redact) the number(s) before filing this declaration.)

   I was not paid by an employer because I was either self-employed only, or not employed.

Date: __________________________________ _____________________________________ Printed name of Debtor 1 Signature of Debtor 1

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

December 2015 Page 1 F 1002-1.EMP.INCOME.DEC

Declaration of Debtor 2 (Joint Debtor) (if applicable)

2. I am Debtor 2 in this case, and I declare under penalty of perjury that the following information is true and correct:

   During the 60-day period before the Petition Date (Check only ONE box below): I was paid by an employer. Attached are copies of all statements of earnings, pay stubs, or other proof of employment income I received from my employer during this 60 day period. (If the Debtor’s social security number or bank account is on a pay stub or other proof of income, the Debtor must cross out (redact) the number(s) before filing this declaration.)

   I was not paid by an employer because I was either self-employed only, or not employed.

Date: __________________________________ _____________________________________ Printed name of Debtor 2 Signature of Debtor 2

This form is mandatory. It has been approved for use in the United States Bankruptcy Court for the Central District of California.

December 2015 Page 2 F 1002-1.EMP.INCOME.DEC