UNITED STATES BANKRUPTCY COURT DISTRICT OF NEW JERSEY Caption in Compliance with D.N.J. LBR 9004-2(c) In Re: Case No.: __________________ Hearing Date: __________________ Chapter: __________________ Judge: __________________ CERTIFICATION OF SECURED CREDITOR REGARDING POST-PETITION PAYMENT HISTORY ON VEHICLE LOAN/LEASE __________________________________ of full age, employed as _________________________________________ by _________________________________________, hereby certifies the following information: Vehicle lender/lessor: ________________________________________ Vehicle description: _________________________________________ POST-PETITION PAYMENTS RECEIVED (Petition filed on __________________) Amount due Date Payment due Date payment received Amount received How payment applied (mo./yr) Type of payment (See Legend below) 1. 2. 3. 4. 5. 6. 7. 8. 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) 9. 10. 11. 12. Total (Continue on attached sheets if necessary) Monthly payments past due @ $________________ per month from ______________ to ______________ : $_____________ Plus miscellaneous amounts due: Late Charges: $_____________ Repossession fees: $_____________ Extension fees: $_____________ Other : $_____________ TOTAL POST-PETITION PAST DUE…………………………………. $ _______________ Pre-petition arrears: _______________ to _________________ (______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 foregoing is true and correct. ________________________________ Date of signature ________________________________ Signature Local Form 16A. rev.8/1/06.jml American LegalNet, Inc. www.FormsWorkflow.com