Fill in this information to identify your case: Debtor 1 Debtor 2 __________________________________________________________________ First Name Middle Name Last Name (Spouse, if filing) First Name ________________________________________________________________ Middle Name Last Name United States Bankruptcy Court for the: ______________________ District of ________ (State) Case number (If known) ___________________________________________ Official Form 101B Statement About Payment of an Eviction Judgment Against You Fill out this form only if: you filed Initial Statement About an Eviction Judgment Against You (Official Form 101A); and you served a copy of Form 101A on your landlord; and you want to stay in your rented residence for more than 30 days after you file your Voluntary Petition for Individuals Filing for Bankruptcy (Official Form 101). File this form within 30 days after you file your Voluntary Petition for Individuals Filing for Bankruptcy (Official Form 101). Also serve a copy on your landlord within that same time period. 12/15 Certification About Applicable Law and Payment of Eviction Judgment I certify under penalty of perjury that (Check all that apply): Under the state or other nonbankruptcy law that applies to the judgment for possession (eviction judgment), I have the right to stay in my residence by paying my landlord the entire delinquent amount. Within 30 days after I filed my Voluntary Petition for Individuals Filing for Bankruptcy (Official Form 101), I have paid my landlord the entire amount I owe as stated in the judgment for possession (eviction judgment). ____________________________________________ Signature of Debtor 1 Date _________________ MM / DD / YYYY ____________________________________________ Signature of Debtor 2 Date _________________ MM / DD / YYYY You must serve your landlord with a copy of this form. Check the Bankruptcy Rules (http://www.uscourts.gov/rules-policies/current-rules-practice-procedure) and the court's local website (go to http://www.uscourts.gov/court-locator to find your court's website) for any specific requirements that you might have to meet to serve this statement. Official Form 101B Statement About Payment of an Eviction Judgment Against You American LegalNet, Inc. www.FormsWorkFlow.com 17