UNITED STATES BANKRUPTCY COURT DISTRICT OF NEW JERSEY Caption in Compliance with D.N.J. LBR 9004-1(b) In Re: Case No.: Chapter: _________________ _________________ Hearing Date: _________________ Judge: _________________ CERTIFICATION REGARDING CALCULATION OF AMOUNT DUE (NOTE AND MORTGAGE DATED _______________________ ) __________________________________ of full age, employed as ______________________________ by _________________________________________, hereby certifies the following: Recorded on _________________, in _________________ County, in Book __________ at Page ______ Property Address: ______________________________________________________________________ Mortgage Holder: ______________________________________________________________________ 1. PAYOFF STATEMENT Unpaid Principal Balance: $ __________________ $ __________________ Accrued interest from __________________ to __________________ : (Interest rate = ________ % per year; $ ______________ per day x ___________days) Unearned interest from ____________________ to _____________________ : $ __________________ Per diem interest from _____________________ to __________________ : Late Charges from ___________ to __________ ($ ______________ /mo. x ______ mos.): $ __________________ $ __________________ $ __________________ Attorney's fees and costs as of ______________________ : American LegalNet, Inc. www.FormsWorkFlow.com Advances through __________________________ for: Real Insurance Other: Sub-Total of Advances: Less Escrow Monies: Net Advances: Interest on advances from ____________ to ________________: Other charges (specify __________________________________): Less unearned interest: ($ $ ($ Estate Taxes: premiums: $ $ _________________ _________________ $ _________________ $ _________________ ________________) $ _________________ _________________ $ _________________ _________________) $ _________________ TOTAL DUE AS OF _______________________: Date of last payment: _______________________ II. EQUITY ANALYSIS (When appropriate) Estimated fair market value of real estate as of _______________________ : $ _________________* *Source: _____________________________ (e.g. appraisal, tax bill/assessment, contract of sale, debtor's schedules, etc.) Liens on the real estate: 1. Real estate taxes as of ___________________ : 2. First Mortgage (principal and interest), as of ________________ : 3. Second Mortgage (principal and interest), as of ______________ : 4. Other (specify on separate exhibit): TOTAL LIENS : APPARENT EQUITY AS OF ______________________: ** If negative, insert zero (0). $__________________ $ __________________ $ __________________ $ __________________ ($ _________________) $ __________________** I certify under penalty of perjury that the above is true. Date: _______________________________ ________________________________ Signature rev.8/1/15 2 American LegalNet, Inc. www.FormsWorkFlow.com