Attorney or Party Name, Address, Telephone & FAX Numbers, and California State Bar Number G G FOR COURT USE ONLY Attorney for Pro Se Debtor CHAPTER 13 UNITED STATES BANKRUPTCY COURT CENTRAL DISTRICT OF CALIFORNIA CASE NUMBER In re Debtor(s). I, DECLARATION SETTING FORTH POST PETITION, PRECONFIRMATION PAYMENTS ON: 1. LEASES OF PERSONAL PROPERTY; 2. PURCHASE MONEY SECURITY LIENS IN PERSONAL PROPERTY (Debtor’s name), hereby declare: 1. I am the debtor in this chapter 13 bankruptcy case that was filed on ________________________. 2. PERSONAL PROPERTY LEASES1 A. I am the obligor (Lessee) on lease(s) of personal property as set forth below. Property Description2 Lessor’s Name Acct. No. (last 4 digits) Due Date3 Date Late 1 Attach additional pages as necessary. 2 Include make, model, and year as applicable. 3 Payment Amount “Due Date” refers to the last day the Payment can be paid without a late charge penalty. This form is mandatory. It has been approved for use by the United States Bankruptcy Court for the Central District of California. January 2009 F 3015-1.10 Declaration Setting Forth Post Petition, Preconfirmation Payments On: Leases of Personal Property; Purchase Money Security Liens in Personal Property Page 2 of 5 In re CHAPTER 13 Debtor(s). B. CASE NUMBER The following are the post-petition payments4 up to the date of plan confirmation (the “Payments”) that I have caused to be mailed/delivered5 to the appropriate Lessor as required pursuant to 11 U.S.C. § 1326(a)(1)(B). Lessor 3. F 3015-1.10 Payment Amount Due Date Date Tendered Method of Delivery PURCHASE MONEY SECURITY CONTRACTS FOR PERSONAL PROPERTY A. I am the obligor on a contract for the sale of personal property subject to a purchase money security interest as set forth below. Property Description 4 Creditor’s Name Acct. No. (last 4 digits) Due Date Date Late Payment Amount Post petition payments are payments that first become due after the bankruptcy filing date. 5 A U. S. Postal Service Certificate of Mailing, stamped by a Postal Service employee, must be obtained for each mailed Payment and copies of the Certificates of Mailing must be attached. If Payments were not mailed, Debtor must state how the Payments were delivered to the Lessor/Creditor and must provide documents that prove that the Payments have been delivered. For example, a copy of a statement, signed by the Lessor/Creditor’s representative, acknowledging receipt of the Payment(s), would provide such proof. This form is mandatory. It has been approved for use by the United States Bankruptcy Court for the Central District of California. January 2009 F 3015-1.10 Declaration Setting Forth Post Petition, Preconfirmation Payments On: Leases of Personal Property; Purchase Money Security Liens in Personal Property Page 3 of 5 In re F 3015-1.10 CHAPTER 13 Debtor(s). B. Creditor CASE NUMBER The following are the post-petition Payments up to the date of plan confirmation that I have caused to be mailed/delivered to the appropriate Creditor pursuant to 11 U.S.C. § 1326(a)(1)(C). Payment Amount Due Date Date Tendered Method of Delivery 4. The Payments set forth above were in the form of money order, cashier’s check, wire transfer, or other certified funds payable to the appropriate Creditor and had written on each item my name, the bankruptcy case number and the appropriate loan number. 5. Attached to this declaration are copies of the: __ cashier’s checks __ money orders __ certified funds, or __ other proof of the Payments described in Paragraphs 2B and 3B above. 6. Also attached to this declaration are copies of the: __ U. S. Post Office Certificate(s) of Mailing, stamped by a U. S. Postal Service employee. __ acknowledgment(s) signed by the Lessor/Creditor’s representative, or __ other documents that prove delivery of the Payments described in Paragraphs 2B and 3B above. I declare under penalty of perjury that the foregoing is true and correct. Dated: _______________________________ ____________________________________ Debtor This form is mandatory. It has been approved for use by the United States Bankruptcy Court for the Central District of California. January 2009 F 3015-1.10 Declaration Setting Forth Post Petition, Preconfirmation Payments On: Leases of Personal Property; Purchase Money Security Liens in Personal Property Page 4 of 5 In re F 3015-1.10 CHAPTER 13 Debtor(s). CASE NUMBER NOTE: When using this form to indicate service of a proposed order, DO NOT list any person or entity in Category I. Proposed orders do not generate an NEF because only orders that have been entered are placed on a CM/ECF docket. PROOF OF SERVICE OF DOCUMENT I am over the age of 18 and not a party to this bankruptcy case or adversary proceeding. My business address is: A true and correct copy of the foregoing document described as will be served or was served (a) on the judge in chambers in the form and manner required by LBR 5005-2(d), and (b) in the manner indicated below: I. TO BE SERVED BY THE COURT VIA NOTICE OF ELECTRONIC FILING (“NEF”) - Pursuant to controlling General Order(s) and Local Bankruptcy Rule(s) (“LBR”), the foregoing document will be served by the court via NEF and hyperlink to the document. On ________________________ I checked the CM/ECF docket for this bankruptcy case or adversary proceeding and determined that the following person(s) are on the Electronic Mail Notice List to receive NEF transmission at the email addressed indicated below: 9 Service information continued on attached page II. SERVED BY U.S. MAIL OR OVERNIGHT MAIL (indicate method for each person or entity served): On _________________________ I served the following person(s) and/or entity(ies) at the last known address(es) in this bankruptcy case or adversary proceeding by placing a true and correct copy thereof in a sealed envelope in the United States Mail, first class, postage prepaid, and/or with an overnight mail service addressed as follow. Listing the judge here constitutes a declaration that mailing to the judge will be completed no later than 24 hours after the document is filed. 9 Service information continued on attached page III. SERVED BY PERSONAL DELIVERY, FACSIMILE TRANSMISSION OR EMAIL (indicate method for each person or entity served): Pursuant to F.R.Civ.P. 5 and/or controlling LBR, on _______________________ I served the following person(s) and/or entity(ies) by personal delivery, or (for those who consented in writing to such service method) by facsimile transmission and/or email as follows. Listing the judge here constitutes a declaration that mailing to the judge will be completed no later than 24 hours after the document is filed. 9 Service information continued on attached page I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct. _________________________________________________________ Date Type Name _____________________________________ Signature This form is mandatory. It has been approved for use by the United States Bankruptcy Court for the Central District of California. January 2009 F 3015-1.10 Declaration Setting Forth Post Petition, Preconfirmation Payments On: Leases of Personal Property; Purchase Money Security Liens in Personal Property Page 5 of 5 In re F 3015-1.10 CHAPTER 13 Debtor(s). CASE NUMBER ADDITIONAL SERVICE INFORMATION (if needed): This form is mandatory. It has been approved for use by the United States Bankruptcy Court for the Central District of California. January 2009 F 3015-1.10