Official Form 417A (12/18) Official Form 417A Notice of Appeal and Statement of Election page 1 [Caption as in Form 416A, 416B, or 416D, as appropriate] NOTICE OF APPEAL AND STATEMENT OF ELECTION Part 1: Identify the appellant(s) 1. Name(s) of appellant(s): 2. Position of appellant(s) in the adversary proceeding or bankruptcy case that is the subject of this appeal: For appeals in an adversary proceeding. Plaintiff Defendant Other (describe) For appeals in a bankruptcy case and not in an adversary proceeding. Debtor Creditor Trustee Other (describe) Part 2: Identify the subject of this appeal 1. Describe the judgment, order, or decree appealed from: 2. State the date on which the judgment, order, or decree was entered: Part 3: Identify the other parties to the appeal List the names of all parties to the judgment, order, or decree appealed from and the names, addresses, and telephone numbers of their attorneys (attach additional pages if necessary): 1. Party: Attorney: 2. Party: Attorney: American LegalNet, Inc. www.FormsWorkFlow.com Official Form 417A Notice of Appeal and Statement of Election page 2 Part 4: Optional election to have appeal heard by District Court (applicable only in certain districts) If a Bankruptcy Appellate Panel is available in this judicial district, the Bankruptcy Appellate Panel will hear this appeal unless, pursuant to 28 U.S.C. 247 158(c)(1), a party elects to have the appeal heard by the United States District Court. If an appellant filing this notice wishes to have the appeal heard by the United States District Court, check below. Do not check the box if the appellant wishes the Bankruptcy Appellate Panel to hear the appeal. Appellant(s) elect to have the appeal heard by the United States District Court rather than by the Bankruptcy Appellate Panel. Part 5: Sign below Date: Signature of attorney for appellant(s) (or appellant(s) if not represented by an attorney) Name, address, and telephone number of attorney (or appellant(s) if not represented by an attorney): Fee waiver notice: If appellant is a child support creditor or its representative and appellant has filed the form specified in 247 304(g) of the Bankruptcy Reform Act of 1994, no fee is required. [Note to inmate filers: If you are an inmate filer in an institution and you seek the timing benefit of Fed. R. Bankr. P. 8002(c)(1), complete Director222s Form 4170 (Declaration of Inmate Filing) and file that declaration along with the Notice of Appeal.] American LegalNet, Inc. www.FormsWorkFlow.com