Attorney or Party Name, Address, Telephone & FAX Nos., State Bar No. & Email Address FOR COURT USE ONLY Individual Lessor appearing without an attorney Attorney for: UNITED STATES BANKRUPTCY COURT CENTRAL DISTRICT OF CALIFORNIA - **SELECT DIVISION**DIVISION In re: CASE NO.: ADVERSARY NO.: CHAPTER: SELECT CHAPTER Debtor(s). LESSOR'S CERTIFICATION OF (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)) Plaintiff(s), vs. Defendant(s). 1. (Lessor) hereby certifies the following regarding that residential property commonly known as (complete address) (Property): (check all that apply) a. The Property is the subject of an eviction action in which possession is sought, filed by the Lessor before in the petition was filed in this case. The eviction action was filed on (Describe Court and Case No.) (Eviction Action). A copy of the complaint filed in the Eviction Action is . attached as Exhibit This form is optional. It has been approved for use in the United States Bankruptcy Court for the Central District of California. December 2012 Page 1 F 4001-1.4.LESSOR.CERT b. Debtor has endangered the property, or used or allowed illegal use of controlled substances on the property, as shown by the following facts: continuation page(s) attached. c. The conduct described in paragraph (b): 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. 2. Lessor has has not filed and served on Debtor and parties in interest a declaration(s) supporting this has has not filed and served on Debtor and parties in interest a memorandum of points and certification, and authorities supporting Lessor's rights under 11 U.S.C. § 362, subsections (m)(1), (m)(2)(D), and (b)(23). Declaration of Lessor I, am the lessor, an officer or authorized agent of the Lessor of the Property described herein. I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct. Date: By: Signature of Lessor or agent of the Lessor Name: Print name of Lessor or agent of the Lessor Name: Print name of law firm representing the Lessor (if applicable) By: Signature of attorney representing the Lessor (if applicable) Name: Print name of attorney representing Lessor (if applicable) This form is optional. It has been approved for use in the United States Bankruptcy Court for the Central District of California. December 2012 Page 2 F 4001-1.4.LESSOR.CERT 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 entitled: LESSOR'S CERTIFICATION OF (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)) will be served or was served (a) on the judge in chambers in the form and manner required by LBR 50052(d); and (b) in the manner stated below: 1. TO BE SERVED BY THE COURT VIA NOTICE OF ELECTRONIC FILING (NEF): Pursuant to controlling General Orders and LBR, the foregoing document will be served by the court via NEF and hyperlink to the document. On (date) , I checked the CM/ECF docket for this bankruptcy case or adversary proceeding and determined that the following persons are on the Electronic Mail Notice List to receive NEF transmission at the email addresses stated below: Service information continued on attached page 2. SERVED BY UNITED STATES MAIL: , I served the following persons and/or entities at the last known addresses in this bankruptcy On (date) 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 addressed 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. Service information continued on attached page 3. SERVED BY PERSONAL DELIVERY, OVERNIGHT MAIL, FACSIMILE TRANSMISSION OR EMAIL (state method for each person or entity served): Pursuant to F.R.Civ.P. 5 and/or controlling LBR, on (date) , I served the following persons and/or entities by personal delivery, overnight mail service, 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 personal delivery on, or overnight mail to, the judge will be completed no later than 24 hours after the document is filed. Service information continued on attached page I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct. Date Printed Name Signature This form is optional. It has been approved for use in the United States Bankruptcy Court for the Central District of California. December 2012 Page 3 F 4001-1.4.LESSOR.CERT