OFFICIAL LOCAL FORM 13 UNITED STATES BANKRUPTCY COURT DISTRICT OF MASSACHUSETTS In re Case No. Chapter Debtor MOTION FOR RELIEF FROM STAY - REAL ESTATE WORKSHEET (To be attached to Motion for Relief from Stay) I_______________________of ____________________________________________________ (Name and Title) (Name of Organization/Corporation/Moving Party) (hereinafter, “Movant”) hereby declare (or certify, verify, or state): BACKGROUND INFORMATION 1. (a) Date chapter 13 petition was filed (If case has been converted from Chapter 7 to Chapter 13, provide date of petition and date of conversion): (b) Address of real property which is the subject of this motion: ________________ _______________________________________________________________________. 2. (a) Original Mortgagee’s Name and Address: ________________________________ _______________________________________________________________________. (b) Name and Address of Current Mortgage Holder: __________________________ _______________________________________________________________________. (c) Name of Note Holder, if different than Mortgage Holder: ___________________ _______________________________________________________________________. 3. Date of Mortgage: ___________________________. 4. Post-Petition payment address, if different than above: __________________________ 222 American LegalNet, Inc. www.FormsWorkFlow.com _______________________________________________________________________. 5. The manner in which the Movant perfected its interest in the property: _____________ _______________________________________________________________________. 6. Other collateral securing the note: __________________________________________ _______________________________________________________________________. 7. Other liens and encumbrances affecting the property in the order of their priority: Names of Senior Lien holder Amount Due Source of Information (e.g., Schedules filed by Debtor(s), public records) Amount Due Source of Information Movant’s Lien Names of Junior Lien holders 8. Existence and Date of Recorded Homestead (if known): ___________________. DEBT/VALUE REPRESENTATIONS 9. Total pre-petition and post-petition indebtedness of Debtor(s) to Movant at the time of filing the motion: $ ____________. (Note: this amount may not be relied on as a “payoff” quotation.) 10. (a) Movant’s estimated fair market value of the real property: $ ______________. 223 American LegalNet, Inc. www.FormsWorkFlow.com (b) Source of estimated fair market valuation: ____________________________. (c) Liquidation value of the real property: ________________________________. STATUS OF DEBT AS OF THE PETITION DATE 11. (a) Total pre-petition indebtedness of Debtor(s) to Movant as of petition filing date: $____________. (b) Amount of principal: $ ____________. (c) Amount of interest: $ ____________. (d) Amount of escrow (taxes and insurance): $ ____________. (e) Amount of forced placed insurance expended by Movant: $____________. (f) Amount of Attorney’s fees billed to Debtor(s) pre-petition: $ ____________. (g) Amount of pre-petition late fees, if any, billed to Debtor(s): $ ____________. 12. Contractual interest rate: _______(If interest rate is (or was) adjustable, please list the rate(s) and dates(s) the rate(s) was/were in effect on a separate sheet and attach the sheet as an exhibit to this form; please list the exhibit number here: __.) 13. Explain any additional pre-petition fees, charges or amounts charged to the account of the Debtor(s) and not listed above: ___________________________ (If additional space is needed, list the amounts on a separate sheet and attach the sheet as an exhibit to this form; list the exhibit number here: __). 224 American LegalNet, Inc. www.FormsWorkFlow.com AMOUNT OF ALLEGED POST-PETITION DEFAULT (AS OF __________ MM/DD/YYYY) 14. Date last payment was received: _____________________ (mm/dd/yyyy). 15. Total number of post-petition payments due from the date of the filing of petition through the date of this Motion or (mm/dd/yyyy): ________________. SCHEDULE OF POST-PETITION PAYMENTS IN DEFAULT (Do not substitute computer generated internal accountings): Paym’t Due Date Amt. of Paym’t Due Amt. of Paym’t Rec’d Totals $ $ Date Paym’t Rec’d Amt. Applied to Principal Amt. Applied to Interest Amt. Applied to Escrow $ $ $ Late Fee Charged if any Amt. Not Applied $ 16. Amount of Movant’s Attorneys’ fees charged to Debtor to date for the preparation and filing of this Motion: $ ________. 17. Other Attorneys’ fees charged to Debtor post-petition: $ ________. 18. Amount of Movant’s post-petition inspection fees: $ ________. 225 American LegalNet, Inc. www.FormsWorkFlow.com 19. Amount of Movant’s post-petition appraisal/broker’s price opinion: $ ______. 20. Amount of forced placed insurance or insurance provided by the Movant post-petition: $______________. 21. Sum held in suspense by Movant in connection with this contract, if applicable: $ ______________. 22. Amount of other post-petition advances or charges (e.g. real estate taxes, insurance): $ ______________. 23. Total amount of postpetition default, including all payments, fees, and charges: $______________. 24. Amount and date of post-petition payments offered by the Debtor(s) and refused by the Movant: Amount(s) $_____________; Date(s): _________________________. REQUIRED ATTACHMENTS TO MOTION Attach the following documents to this motion and indicate the exhibit number associated with the documents: (1) Copies of documents that indicate Movant’s interest in the subject property. For purposes of example only, a complete and legible copy of the promissory note or other debt instrument together with a complete and legible copy of the mortgage and any assignments in the chain from the original mortgagee to the current moving party. (Exhibits _____.) (2) Copies of documents establishing proof of standing to bring this motion if different from the above. (Exhibits_____.) (3) Copies of documents establishing that Movant’s interest in the real property is perfected. For the purposes of example only, a complete and legible copy of the Financing Statement (UCC-1) filed with either the Clerk’s Office or the Register of the county the property is located in. (Exhibits _______.) 226 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION AND DECLARATION FOR BUSINESS RECORDS The undersigned certifies that the information provided in this worksheet and any exhibits attached to this worksheet (other than transactional documents attached as required in paragraphs (1) through (3) above) are derived from records that (a) were made at or near the time of the occurrence of the matters set forth by, or from information transmitted by a person with knowledge of those matters; and (b) were prepared and kept in the regular course of business. In the event the Worksheet is not fully completed, Movant shall explain the reasons therefor and the reasonable efforts made to obtain the information.___________________ ______________________________________________________________________________ The undersigned further certifies that copies of any transactional documents attached to this worksheet as required by paragraphs 1, 2, or 3, immediately above, are true and accurate copies of the original documents. The undersigned further certifies that the original documents are in Movant’s possession, except as follows: ______________________________. I/WE DECLARE UNDER THE PENALTY OF PERJURY THAT THE FOREGOING REPRESENTATIONS OF FACT ARE TRUE AND CORRECT TO THE BEST OF MY/OUR KNOWLEDGE AND BELIEF. _________________________________ Signature _______________________ Date _________________________________ Printed Name ______________________________________________________________________ Title and Organization 227 American LegalNet, Inc. www.FormsWorkFlow.com