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IN THE UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF VIRGINIA

IN RE:______CASE NO.______Debtor’s Name Social Security No. XXXX-XX-_____

______Chapter 13 Debtor’s Name Social Security No. XXXX-XX-_____

AFFIDAVIT BY DEBTOR(S) REGARDING INCOME TAX RETURN FILINGS

The Debtor(s) in this case hereby declare(s) and affirm(s) as follows:

1. I/we have not filed Federal, State and local tax returns for the four year period ending on the date of the filing of this bankruptcy case for the following reasons (state the year and the reason why not filed for each such year):

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2. The tax returns referenced in paragraph number 1 above have not been required to be filed because (provide the basis for each such year not filed; reference the applicable legal authority if any) ______

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By signing this affidavit, I/we declare and affirm that I/we have read the foregoing statements, and that they are true, accurate and complete to the best of my/our knowledge, information, and belief.

Date:______Signature:______Debtor’s name:______[Print]

Date:______Signature:______Debtor’s name:______[Print]

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