(Attorney Name)

(Firm Name)

(Address)

(City, State, Zip)

Telephone: ( )

Fax: ( )

Email: ( )

Attorney for: ( )	AK LBF 38

[11/15]

UNITED STATES BANKRUPTCY COURT

FOR THE DISTRICT OF ALASKA

In re:

(Debtor's Name) and

(Joint Debtor's Name),

Debtor(s).

Case No. ( )

Chapter ( )

Statement under Penalty of Perjury

Concerning Payment Advices Due

Pursuant to 11 U.S.C. § 521(a)(1)(B)(iv)

I,	, state as follows:

I have not filed with the court copies of all payment advices or other evidence of payment received within 60 days prior to the filing of my petition from any employer because:

(__)	I am self employed and did not receive any payments from an employer within the 60 day period before the filing of my petition;

(__)	My only income during the 60 day period before the filing of my petition was from Social Security, pensions, or disability payments, or from rental or investment income.

(__)	I was not employed during the 60 day period immediately preceding the filing of my petition.

(__)	Other. Specify:

I declare, under penalty of perjury under the laws of the United States of America that the foregoing is true and correct.

Executed on:

Date

________________________________

(signature of debtor)