UNITED STATES BANKRUPTCY COURT DISTRICT OF NEW JERSEY Caption in compliance with D.N.J. 9004-1(b) In Re: Case No.: Hearing Date: Chapter: Judge: _____________________ _____________________ _____________________ _____________________ CERTIFICATION OF CREDITOR REGARDING POST PETITION PAYMENT HISTORY (VEHICLE LOAN/LEASE) __________________________________ , employed as _________________________________________ by _________________________________________, hereby certifies the following: Vehicle lender/lessor: ________________________________________ Vehicle description: _________________________________________ POST-PETITION PAYMENTS RECEIVED (Petition filed on __________________________ ) Amount due 1. 2. 3. 4. 5. 6. Date Payment due Date payment received Amount received How payment applied (mo/yr) Type of payment (See Legend below) American LegalNet, Inc. www.FormsWorkFlow.com Amount due Date Payment due Date Payment received Amount Received How Payment applied (mo/yr) Type of Payment (See Legend below) 7. 8. 9. 10. 11. 12. T TOTAL: $ 0.00 [Continue on attached sheets if necessary] $ 0.00 Monthly payments past due at $__________ per month from _________ Plus miscellaneous amounts due: Late Charges: Repossession fees: Extension fees: Other: ___ to _________ ____ : $_____________ $ _______________ $ _______________ $ _______________ $ _______________ 0.00 TOTAL POST-PETITION PAST DUEYYYYYYYY.. $ _______________ Pre-petition arrears: _______________ to _________________ 0.00 ( ________ months x $_____________ per month = $____________ ) Legend: MP = monthly payment; EXF = Extension fee; LC = Late Charge; O = Other *specify other payments received I certify under penalty of perjury that the above is true. Date: ________________________________ ________________________________ Signature rev.8/1/15 2 American LegalNet, Inc. www.FormsWorkFlow.com