Form Number LR 4001-1 () UNITED STATES BANKRUPTCY COURT FOR THE NORTHERN DISTRICT OF ALABAMA DIVISION In re: } Case No. } Chapter } } Debtor(s) } FACT SUMMARY SHEET FOR MOTION FOR RELIEF FROM AUTOMATIC STAY OR FOR ADEQUATE PROTECTION IN CHAPTER 7 AND 13 CASES Type of Loan/Credit Transaction: Date of Loan/Credit Transaction Type of Collateral: Monthly Payment: Amount Financed: APR or Interest Rate: Term of Loan: months or years Payoff Amount: as of (Date) Value of Collateral and Basis: (Value) as of (Date) and (Basis) Address of real property: Delinquent Pre-Petition Payments: What Month(s)? Amount? Claim filed? Yes No Date claim filed: Claim Number Number of Months of Pre-Petition Payment Default Put into Debtor's Chapter 13 Plan: Delinquent Post-Petition Payments: What Month(s)? Amount of mortgage payments? Late Charges? Court Costs / Attorney's fees? Total Amount Due Claim filed? Yes No Date claim filed: Claim Number Number of Post-Petition Payments Received (Not How Applied): Number of Post-Petition Payments Held by Creditor but Not Applied to Debt: Number of Post-Petition Payments Returned by Creditor to Debtor: If Lease, Lease Expiration Date: If Terminated, Lease Termination Date: Insurer of Collateral: Term of Insurance: (Expiration Date) Prior Stay Order(s) Involving Movant, Including Current Case: Yes No If yes, give case number(s) and date(s) of order(s) Case No.: Date: Case No.: Date: Case No.: Date: Debtor's Statement of Intention: Date: Submitted by: (signature) American LegalNet, Inc. www.FormsWorkFlow.com