ADVERSARY PROCEEDING COVER SHEET B 104 ADVERSARY PROCEEDING NUMBER (Instructions on Reverse) (Rev. 5/00) (Cou rt Us e On ly) PLAINTIFFS DEFENDANTS ATT OR NEY S (Firm Name, A ddress , and Teleph one No.) ATTO RNEYS (If Known) PARTY (Check one box only) __ 1 U.S. PLAINTIFF _ _ 2 U . S . D E F E N DA N T __ 3 U.S. NOT A PARTY CAUSE OF ACTION ( W R I T E A B R IE F S T A T E M EN T O F C A U S E O F AC T I O N , I N C L UD I N G A LL U . S. S T A T U T ES I N V O LV E D ) NATURE OF SUIT (Chec k the one mos t appropriate ) __456 To obtain a declaratory judgment __455 To revoke an order of confirm ation __454 To Rec over Money or Prop erty of a Chap. 11, Chap. 12, or Chap. Extent of a Lien or Other Interest relating to any of foregoing causes 13 Plan __435 To Determ ine Validity, Priority, or of action __459 To determ ine a claim or cau se of __426 To determ ine the disc hargeability in Property action removed to a bankruptcy of a debt 11 U.S.C. §523 __458 To obtain app roval for the sale of court __434 To obtain an inju nction or other both the interest of the estate and __49 8 O ther (s pecif y) equitable relief of a co-owner in property __45 7 To s ubordin ate any allowed c laim __424 To object or to revoke a discharge or interest except where such 11 U.S.C. § 727 subordin ation is provided in a plan ORIGIN OF PROCEEDINGS __ 1 O riginal __2 R emoved Proceeding __4 Reinstated Proceeding __5 Transferred or Reopened __CHECK IF THIS IS A CLASS from Another F.R.C.P. 23 ACTION UNDER Bank ruptc y (Check One Box O nly) Court DEMAND N E A R E ST T H O U S A N D O T H E R R EL IE F S O U G H T J U R Y D EM A N D BANKRUPTCY CASE IN WHICH THIS ADVERSARY PROCEEDING ARISES NAME OF DEBTOR B A N K R U PT C Y C A SE N O . D I S T R IC T I N W H I C H C A S E I S P EN D I N G DIVISIONAL OFFICE NAME OF JUDGE RELAT ED AD VERSA RY PRO CEED ING (IF ANY) PLAINTIFF D E F E N DA N T A D V E R SA R Y P RO C E E D IN G N O . D I S T RI C T DIVISIONAL OFFICE NAME OF JUDGE FILING (Chec k one box only.) _ _ FE E A T T A C H E D _ _ F EE N O T R E Q U I R ED __FEE IS DEFERRED FEE DATE PRINT NAME SIGNATURE OF ATT ORNEY (OR PLAINTIFF) American LegalNet, Inc. www.USCourtForms.com Local Form 109 INSTRUCTIONS FOR COMPLETING ADVERSARY PROCEEDING COVER SHEET This cover sheet must be com pleted by the pla intiff’s attor ney (or by th e plaintiff i f th e plaintiff i s not r epr esented by an attor ney) and submitted to the Clerk of the Court upon the filing of a complaint initia ting an adversary proceeding. The cover sheet and the information contained on it do not replace or supplement the filing and service of pleadings or other papers as required by law, the Bankruptcy Rules, or the local rules of Court. This form is required for the use of the Clerk of the Court to initiate the docket sheet and to prepare necessary indices and statistical records. A separate cover sheet must be submitted to the Clerk of the Court for each complaint filed. The form is la rgely self explanator y. Parties. The names of the parties to the adversary proceeding exactly as they appear on the complaint. Give the names and addresses of the a ttorneys if known. Following th e headin g “Party,” ch eck the appr opriate box in dicatin g whether the United States is a party named in the complaint. Only parties who may be properly joined pursuant to Rule 7019 should be included. Cause of Action. Give a brief description of the cause of action including all federal statutes involved. For example, “Complaint seekin g damages for failure to disclose infor mati on, Consum er Cr edit Protect ion Act, 15 U.S.C. § 1601, et seq.,” or “Compl aint by trustee to avoid a transfer of property by the debtor, 11 U.S.C. § 544.” Nature of Suit. Place a “X” in the approp riate box. Only one box should be checked. If the cause fits mor e than one categor y of suit, select the most definitive. Origin of Proceedings. Check the a ppropri ate box to indica te the orig in of the case: 1. 2. 4. 5. Original Proceeding. Removed from a State or District Court. Reinstated or Reopened. Transferred from Another Bankruptcy Court. Demand. On th e next line, state the dolla r amount deman ded in the com plaint in th ousan ds of dollars. For $1,000 enter “1," for $10,000, enter “10," for “100,000,” enter “100,” if $1,000,000, enter “1000.” If $10,000,000 or more, enter “9999.” If the amount is less than $1, 000, enter “0001.” If n o monetary dem and is made, enter “XXXX.” If the plain tiff is seeking non-monetary relief, state the relief sought, such as in junction or foreclosure of a mortg age. Bankruptcy Case In Whic h This Adversary Proceeding Arise s. Enter the name of the debtor and the docket number of the bankruptcy case from which the pr oceeding now being filed arose. Beneath, ent er the distri ct and divisional office where the case was filed, an d the na me of the presid ing judge. Related Adversary Procee dings. State the names of the parties and the six digit adversary proceeding number from any adversary proceeding con cernin g the sam e two parties or t he same pr operty curren tly pendin g in an y bankruptcy court. On the n ext line, enter the distr ict where th e related case i s pendin g, and t he nam e of the presiding judge. Filing Fee. Check one box. The fee must be paid upon filing unless the plaintiff meets one of the following exceptions. The fee is not required if the plaintiff is the United States government or the debtor. If the plaintiff is the trustee or a debtor in possession, and there are no liquid funds in the estate, the filing fee may be deferred until there are funds in the estate. (In the event no funds are ever recovered for th e estate, th ere will be no fee). Th ere is no fee for adding a par ty after the ad versary proceedin g has been commenced. Signature. This cover sheet must be signed by the attorney of record in the box on the right of the last line of the form. If the plaintiff is repr esented by a law firm, a member of the firm must sign . If the plaint iff is pro se, that is, not represented by an attorney, the plaintiff must sign. The name of the signatory must be printed in the box to the left of the signature. The date of the signing must be indicated in the box on the far l eft of the last line. Local Form 109 (pg. 2) American LegalNet, Inc. www.USCourtForms.com