CANB — Statement Re Payment Advices

Source: https://www.canb.uscourts.gov/sites/default/files/forms/Statement%20Re%20Payment%20Advices%20Revised%20March%202017.pdf

Provide this completed form to the trustee assigned to your bankruptcy case. Do not file this form with the Court. In accordance with Bankruptcy Rule 9037, redact social security numbers, financial account numbers and other personal data identifiers appearing on attachments to this form.

UNITED STATES BANKRUPTCY COURT
NORTHERN DISTRICT OF CALIFORNIA

In Re: ) Case Number: Chapter Number:
)
)
Debtor(s) )

STATEMENT RE PAYMENT ADVICES

Attached are copies of all payment advices (employment pay stubs) that I/we received from my/
our employer(s) within 60 days before the filing of this bankruptcy case.

My/our payment advices for the 60 day period before the filing of this bankruptcy case are not
available. Attached is a certification stating why my/our payment advices are unavailable,
providing an estimate of payments received within the 60 day period and also providing other
evidence, if any, of the payments received.

I/we declare under penalty of perjury that the above statement is true and correct to the best of my/our
knowledge, information, and belief.

Date:
Signature of Debtor

Date:
Signature of Joint Debtor

Date:
Signature of Attorney
DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION PREPARER (See 11 U.S.C. § 110)
I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in 11
U.S.C. § 110; (2) I prepared this document for compensation and have provided the debtor with a copy
of this document and the notices and information required under 11 U.S.C. §§ 110(b), 110(h) and
342(b); and (3) if rules or guidelines have been promulgated pursuant to 11 U.S.C. § 110(h) setting a
maximum fee for services chargeable by bankruptcy petition preparers, I have given the debtor notice
of the maximum amount before preparing any document for filing for a debtor or accepting any fee from
the debtor, as required by that section.
Print or Type Name of Bankruptcy Petition Preparer: Social Security Number:

If the bankruptcy petition preparer is not an individual, state the name, title (if any), address, and
social security number of the officer, principal, responsible person, or partner who signs this document:

Signature of Bankruptcy Petition Preparer: Date:

Names and Social Security numbers of all other individuals who prepared or assisted in preparing this document, unless the bankruptcy petition preparer is not an individual:

If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for each person. A bankruptcy petition preparer’s failure to comply with the provisions of title 11 and the Federal Rules of Bankruptcy Procedure may result in fines or imprisonment or both. 11 U.S.C. §110; 18 U.S.C. §156.

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