UNITED STATES BANKRUPTCY COURT - WESTERN DISTRICT OF NEW YORK Request for Clerk's Certificate or Certified Copy of Document (Part 1, Required) Request By: Mailing Address: Debtor Name: _________________________________________________ Phone #: __________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ___________________________________________ Case Number: ________________ Chapter: ____ ---------------------------------------------------------------------------------------------------------------------------------------------------------------- Item(s) Requested: (Part 2, Required) _____ Certificate of Search $11.00 _____ *Certificate of Abandonment (Chapter 7 cases, if 11 USC 554(c) elements satisfied) $11.00 Property Address:___________________________________________________________________________ _____ *Certified Copy ­ Order of Abandonment $11.00 plus 50 cents per page Property Address:___________________________________________________________________________ _____ *Certified Copy Discharge Order $11.00 plus 50 cents per page _____ *Certified Copy Dismissal Order $11.00 plus 50 cents per page _____ *Certified Copy ­ 522(f) Order $11.00 plus 50 cents per page _____ *Certified Copy Docket $11.00 plus 50 cents per page _____ *Certified Copy Other $11.00 plus 50 cents per page: _____________________________________________ _____ Other: ______________________________________________________________________________________ *If case file is stored with Federal Records Center, $64.00 retrieval fee due for first box, $39.00 for additional boxes. ---------------------------------------------------------------------------------------------------------------------------------------------------------------- Please choose a form of payment: (Part 3, Required) _____ Credit Card via pay.gov. [Signature is Required.] I hereby authorize the U.S. Bankruptcy Court for the Western District of New York to charge my Electronic Case Filing account for payment of fees, costs, and expenses which are incurred by the delivery of the services requested above. I will receive an email indicating that the service is ready and that my account has been charged. I understand that I will have 48 hours to pay the fee, or my Electronic Case Filing account will be locked until payment is received. ____________________________ ____________________________________________ Date Signature _____ Credit Card. Accepted at the Intake Counter in the Buffalo & Rochester Offices. Credit transactions will not be accepted from current debtors. _____ Check or Money Order. Personal checks will not be accepted from current debtors. _____ Cash. Accepted in the Buffalo Office only (Exact change required). Do not send cash in the mail. ---------------------------------------------------------------------------------------------------------------------------------------------------------------Trustees: _____ Certificate of Trustee Intent to Sell. Circle One: Public Auction or Private Sale Property: __________________________________________________________________________________________ _____ Certificate of Trustee Intent to Abandon. Property: __________________________________________________________________________________________ _____ Certificate of Trustee Appointment. (rev. 4/3/15) Total Amount Due: $ _____________________ Receipt #: ____________________ American LegalNet, Inc. www.FormsWorkFlow.com