UNITED STATES BANKRUPTCY COURT

WESTERN DISTRICT OF MISSOURI

IN RE: Enter debtor(s) name	)

)

)

Debtor(s)	)	Case No. Enter Case No.

)

)

DEBTOR’S EVIDENCE OF NO EMPLOYER PAYMENTS

I, Enter debtor(s) name, hereby state and declare under penalty of perjury that (check the box that applies):

I received no payment from any employer for the 60 days prior to filing the petition.

I received no payment from any employer from Enter text to

Enter text prior to the filing of the petition. Payment advices for the remainder of the 60-day period have been provided.

I was self-employed. Net income for 60 days prior to filing the petition, itemized to show how the amount is calculated is (shown below or in the attachment).

Enter signature

Name of Debtor

Instructions	File as a separate document on the date the voluntary petition is filed.

ECF Event:	Bankruptcy>Other>Debtor Evidence of No Employer Payments