Attorney or Party Name, Address, Telephone & FAX Numbers, and California State Bar Number FOR COURT USE ONLY G Attorney for: G Individual lessor appearing without counsel (Pro Se Lessor) UNITED STATES BANKRUPTCY COURT CENTRAL DISTRICT OF CALIFORNIA CHAPTER: In re: CASE NO.: LESSOR’S CERTIFICATION OF Debtor(s). (1) PREPETITION EVICTION ACTION SEEKING POSSESSION OF RESIDENTIAL PROPERTY BASED ON DEBTOR’S PREPETITION ENDANGERMENT OF PROPERTY OR ILLEGAL USE OF A CONTROLLED SUBSTANCE, OR (2) ENDANGERMENT OF THE PROPERTY OR ILLEGAL USE OF A CONTROLLED SUBSTANCE WITHIN THE LAST 30 DAYS (11 U.S.C. § 362 (b)(23)) 1. ______________________________ (“Lessor”) hereby certifies the following regarding that residential property commonly known as __________________________________________________________________________ (“Property”): (Check all that apply) (Complete Address) a. G The Property is the subject of an eviction action in which possession is sought, filed by the Lessor before the petition was filed in in this case. The eviction action was filed on (Describe Court and Case No.) (the “Eviction Action”). A copy of the complaint filed in the Eviction Action is attached as Exhibit . b. G Debtor has endangered the property, or used or allowed illegal use of controlled substances on the property, as shown by the following facts: G continuation page(s) attached. c. G The conduct described in paragraph (b): G G 2. Is described in the eviction action referred to in paragraph (a); or Occurred during the 30-day period preceding the date this certification was filed and served. Lessor G has G has not filed and served on Debtor and parties in interest a declaration(s) supporting this certification, and G has G has not filed and served on Debtor and parties in interest a memorandum of points and authorities supporting Lessor’s rights under 11 U.S.C. § 362, subsections (m)(1), (m)(2)(D), and (b)(23). (Continued on next page ) This form is optional. It has been approved by the United States Bankruptcy Court for the Central District of California. January 2009 F 4001-1.4 Lessor’s Certification (Endangerment of Property by Debtor) - Page 2 of In re (SHORT TITLE) F 4001-1.4 CHAPTER: Debtor(s). CASE NO.: Declaration of Lessor I, _______________________________, am the G lessor, G an officer or authorized agent of the lessor of the property described herein. I declare under the penalty of perjury that I have read the foregoing, including all continuation pages, and that all statements therein are true and correct. Executed this _________________ day of ____________________, _______________ at _________________ . (Month) (Year) ________________________________________________________ Signature of the Lessor or Agent of the Lessor _________________________________________________________ Print Name of the Lessor or Agent of the Lessor _________________________________________________________ Print the Name of the Law Firm Representing the Lessor (if applicable) _________________________________________________________ Signature of the Attorney Representing the Lessor (if applicable) _________________________________________________________ Print the Name of the Attorney Representing the Lessor (if applicable) This form is optional. It has been approved by the United States Bankruptcy Court for the Central District of California. January 2009 F 4001-1.4 Lessor’s Certification (Endangerment of Property by Debtor) - Page 3 of In re (SHORT TITLE) F 4001-1.4 CHAPTER: Debtor(s). CASE NO.: 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: G 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. G 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. G 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 optional. It has been approved by the United States Bankruptcy Court for the Central District of California. January 2009 F 4001-1.4 Lessor’s Certification (Endangerment of Property by Debtor) - Page 4 of In re (SHORT TITLE) F 4001-1.4 CHAPTER: Debtor(s). CASE NO.: ADDITIONAL SERVICE INFORMATION (if needed): This form is optional. It has been approved by the United States Bankruptcy Court for the Central District of California. January 2009 F 4001-1.4