Attorney or Party Name, Address, Telephone & FAX Numbers, and California State Bar Number FOR COURT USE ONLY Attorney for UNITED STATES BANKRUPTCY COURT CENTRAL DISTRICT OF CALIFORNIA In re: CHAPTER ______ CASE NUMBER DATE: TIME: Debtor. COURTROOM: STATEMENT PURSUANT TO LOCAL BANKRUPTCY RULE 4001-2 (CASH COLLATERAL STIPULATIONS) (Secured Creditor: ________________) The Debtor, through a separately filed motion, has requested the approval of a stipulation providing for the use of cash collateral, or post-petition financing, or both. Attached to the motion as Exhibit ______ is a true and correct copy of the agreement for use of cash collateral or post-petition financing (the “Agreement”), which Agreement contains the following provisions: Description of Provision Page No: Line No. (If Applicable) Cross-collateralization clauses Provisions or findings of fact that bind the estate or all parties in interest with respect to the validity, perfection or amount of the secured party’s lien or debt Provisions or findings of fact that bind the estate or all parties in interest with respect to the relative priorities of the secured party’s lien and liens held by persons who are not party to the stipulation, or which create a lien senior or equal to any existing lien Waivers of 11 U.S.C. § 506(c), unless the waiver is effective only during the period in which the debtor is authorized to use cash collateral or borrow funds Provisions that operate, as a practical matter, to divest the debtor in possession of any discretion in the formulation of a plan or administration of the estate or to limit access to the court to seek any relief under other applicable provision of law Releases of liability for the creditor’s alleged prepetition torts or breaches of contract Waivers of avoidance actions arising under the Bankruptcy Code (Continued on next page) This form is optional. It has been approved for use by the U.S. Bankruptcy Court for the Central District of California. January 2009 F 4001-2 F 4001-2 Statement Pursuant to Local Bankruptcy Rule 4001-2 (Cash Collateral Stipulations) - Page 2 of In re (SHORT TITLE) CHAPTER: Debtor(s). CASE NO.: Page No: Description of Provision Line No. (If Applicable) Automatic relief from the automatic stay upon default, conversion to chapter 7, or appointment of a trustee Waivers of procedural requirements, including those for foreclosure mandated under applicable non-bankruptcy law, and for perfection of replacement liens Adequate protection provisions which create liens on claims for relief arising under 11 U.S.C. §§ 506(c), 544, 545, 547, 548 and 549 Waivers, effective on default or expiration, of the debtor’s right to move for a court order pursuant to 11 U.S.C. § 363(c)(2)(B) authorizing the use of cash collateral in the absence of the secured party’s consent Provisions that grant a lien in an amount in excess of the dollar amount of cash collateral authorized under the applicable cash collateral order Provisions providing for the paying down of prepetition principal owed to a creditor Findings of fact on matters extraneous to the approval process Dated: Type Name Signature This form is optional. It has been approved for use by the U.S. Bankruptcy Court for the Central District of California. January 2009 F 4001-2 Statement Pursuant to Local Bankruptcy Rule 4001-2 (Cash Collateral Stipulations) - Page 3 of In re (SHORT TITLE) F 4001-2 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 for use by the U.S. Bankruptcy Court for the Central District of California. January 2009 F 4001-2 Statement Pursuant to Local Bankruptcy Rule 4001-2 (Cash Collateral Stipulations) - Page 4 of In re (SHORT TITLE) F 4001-2 CHAPTER: Debtor(s). CASE NO.: ADDITIONAL SERVICE INFORMATION (if needed): This form is optional. It has been approved for use by the U.S. Bankruptcy Court for the Central District of California. January 2009 F 4001-2