Free Local Bankruptcy Form 4001-1C - New Hampshire

LBF 4001-1C
(Eff. 6/1/09)

UNITED STATES BANKRUPTCY COURT DISTRICT OF NEW HAMPSHIRE
In re: _____________________________________, Debtor(s) Bk. No. ___-________- Select Judge Chapter ___

WORKSHEET COMPLETED BY THE MORTGAGEE/SERVICER IN SUPPORT OF MOTION FOR RELIEF FROM STAY INVOLVING RESIDENTIAL REAL PROPERTY I, ________________________ (name of Movant or, if Movant is a business entity other than an individual, the name and representative capacity of the person signing this worksheet on behalf of such entity and the name of the entity), do hereby declare (or certify, verify, or state):

BACKGROUND INFORMATION 1. 2. 3. 4. Address or general description of the real property that is the subject of this motion Name and address of original mortgagee Dates of the note and mortgage (MM/DD/YYYY) If Movant is different from the original mortgagee, the status of Movant (e.g., holder, assignee, or servicing agent) Current address of Movant Postpetition payment address of Movant if different from address in paragraph 5 above Brief statement of Movant's standing (e.g., first mortgagee, second mortgagee, assignee, servicing agent)

5. 6. 7.

DEBT/VALUE REPRESENTATIONS 8. Total indebtedness of Debtor(s) to Movant at the time of filing the motion. This amount may not be relied upon as a "payoff" quotation. $

9. 10.

Movant's estimated market value of the real property Source of estimated valuation

$

STATUS OF DEBT AS OF THE PETITION DATE 11. Total prepetition indebtedness of Debtor(s) to Movant as of petition filing date $ $ $ $ $ $ $ A. $ B. $ C. $ D. $

A. Amount of principal B. Amount of interest C. Amount of escrow (taxes and insurance) D. Amount of forced placed insurance E. Amount of attorney's fees incurred prepetition that have been or will be charged to the Debtor(s) F. Amount of prepetition late fees, if any, billed to Debtor(s) G. Itemize any additional prepetition fees or costs charged to the Debtor(s)' account and not listed above, including inspection fees, valuation fees, real estate taxes, etc. A separate exhibit may be attached to this worksheet. If so, it is marked Exhibit _______. 12. 13. 14. Number of payments in arrears on the petition date Total amount of prepetition arrearage Contractual interest rate. If interest rate is (or was) adjustable, please list the rate(s) and date(s) the rate(s) was/were in effect. A separate exhibit may be attached to this worksheet. If so, it is marked Exhibit _______.

$

STATUS OF POSTPETITION DEFAULT AS OF ___________ (MM/DD/YYYY) 15. 16. 17. Amount of monthly payment (including principal, interest, and escrow) Date last payment was received (MM/DD/YYYY) Alleged number of contractual payments due postpetition from filing of petition through payment due on __________________ (MM/DD/YYYY) Number of payments in arrears as of above date Please list below all postpetition payments alleged to be in default: Alleged Amount Due Date Alleged Amount Due Amount Received Amount Applied to Principal and Interest Amount Applied to Escrow Late Fee Charged (if any) $

18. 19.

Totals: 20.

$

$

$ $

$

$

Amount of Movant's attorney's fees charged or to be charged to the Debtor(s) for the preparation, filing, and prosecution of this motion Amount of filing fee for this motion Itemize any additional postpetition fees or costs charged or to be charged to the Debtor(s)' account and not listed above, including inspection fees, valuation fees, insurance, real estate taxes, attorney's fees, etc. A separate exhibit may be attached to this worksheet. If so, it is marked Exhibit _______. Sum held in suspense by Movant in connection with this contract, if applicable Total amount of postpetition arrearage 3

21. 22.

$ A. $ B. $ C. $ D. $

23. 24.

Credit of $ $

REQUIRED ATTACHMENTS The following documents are attached to this worksheet in support of the motion and marked as exhibits: 1. Copies of documents showing Movant's interest in the subject property (e.g., a complete and legible copy of the promissory note or other debt instrument together with a complete and legible copy of the mortgage and any assignment in the chain from the original mortgagee to the Movant), which are marked as Exhibits __________. 2. Copies of documents showing proof of standing to bring this motion for relief if different than the above, which are marked as Exhibits __________. CERTIFICATION FOR BUSINESS RECORDS The information provided in this worksheet and/or any exhibits attached to this worksheet (other than the transactional documents attached as required by paragraphs 1 and 2 immediately above) is derived from records that (a) were made at or near the time of the occurrence of the matters set forth by, or from information transmitted by, a person with knowledge of those matters, (b) were kept in the course of the regularly conducted activity, and (c) were made by the regularly conducted activity as a regular practice. Further, the copies of any transactional documents attached to this worksheet, as required by paragraphs 1 and 2 immediately above, are true and accurate copies of the original documents. DECLARATION I ________________________________(Name and Title) of ____________________________ (Name of Movant) hereby declare (or certify, verify, or state) pursuant to 28 U.S.C. § 1746 under penalty of perjury that the foregoing is true and correct based on personal knowledge of the Movant's books and business records. Executed at __________________________(City/Town), _______(State) on this ______ day of ____________(Month), ____(Year). ___________________________________ ________________________(Print Name) _____________________________ (Title) ___________________________(Movant) __________________________ (Address) __________________________ (Address 2) _________________________(City, State) __________________________(Zip Code) 4

REPRESENTATIONS REGARDING OTHER LIENS ATTACHING TO THE PROPERTY I, ________________________ (name of Movant or Movant's attorney), do hereby declare (or certify, verify, or state): Names of Senior Lienholder Amount Due Source of Information (e.g., Debtor's schedules, public records, other)

$ $ $ Movant's lien Names of Junior Lienholder $ Amount Due Source of Information (e.g., Debtor's schedules, public records, other)

$ $ $

___________________________________ _________________________(Print Name) ______________________________ (Title) __________________________ (Address) __________________________ (Address 2) _________________________ (City, State) __________________________ (Zip Code)

5