Free form 16a - New Jersey

UNITED STATES BANKRUPTCY COURT DISTRICT OF NEW JERSEY
Caption in Compliance with D.N.J. LBR 9004-2(c)

In Re:

Case No.: Hearing Date: Chapter: Judge:

__________________ __________________ __________________ __________________

CERTIFICATION OF SECURED CREDITOR REGARDING POST-PETITION PAYMENT HISTORY ON VEHICLE LOAN/LEASE
__________________________________ of full age, employed as _________________________________________ by _________________________________________, hereby certifies the following information:

Vehicle lender/lessor: ________________________________________ Vehicle description: _________________________________________ POST-PETITION PAYMENTS RECEIVED (Petition filed on __________________)
Amount due Date Payment due Date payment received Amount received How payment applied (mo./yr) Type of payment (See Legend below)

1. 2. 3. 4. 5.
6. 7. 8.

Amount due

Date Payment due

Date Payment received

Amount Received

How Payment applied (mo./yr)

Type of Payment (See Legend below)

9. 10. 11. 12. Total
0.00

0.00

(Continue on attached sheets if necessary)

Monthly payments past due @ $________________ per month from ______________ to ______________ : $_____________ Plus miscellaneous amounts due: Late Charges: Repossession fees: Extension fees: Other : $_____________ $_____________ $_____________ $_____________

0.00 TOTAL POST-PETITION PAST DUE........................................ $ _______________

Pre-petition arrears: _______________ to _________________
0.00 (______months x $_____________per month = $____________)
Legend: MP = monthly payment; EXF = Extension fee; LC = Late Charge O = Other*specify other payments received

I certify under penalty of perjury that the foregoing is true and correct.

________________________________ Date of signature

________________________________ Signature

Local Form 16A. rev.8/1/06.jml