LBR Form 4001-1(a) UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF OHIO _____________ DIVISION In re: Case No: Chapter Debtor(s) Judge RELIEF FROM STAY / ADEQUATE PROTECTION EXHIBIT AND WORKSHEET -- REAL ESTATE (For use as required by LBR 4001­1(a)(1)) Real property address which is the subject of this motion: _____________________________________________ DEBT / VALUE REPRESENTATIONS: Total indebtedness of the debtor(s) at the time of filing the motion for relief from stay (not to be relied upon as a payoff quotation) Movant's estimated market value of the real property Source of the estimated valuation STATEMENT OF ARREARAGE: (1) As of petition filing date: Amounts paid after the date of filing to be applied to the prepetition default: (2) Postpetition: (3) Monthly payment amount: (4) Date of Last Payment: (5) Amount of Last Payment: # of payments due postpetition # of payments received postpetition # of payments in default postpetition ________ (through payment due mm/dd/yy) ________ ________ $____________ $____________ $____________ American LegalNet, Inc. www.FormsWorkFlow.com $____________ $____________ _______________________________________________ $____________ $____________ $____________ $____________ _________________ $____________ Total amount of postpetition payments currently in default + Postpetition late charges + Other charges Foreclosure title work Filing fee Skip trace Document acquisition costs Service Process server Escrow Shortage Hazard Insurance Taxes Appraisal BPO charges Property Inspection Other (specify) = Total Postpetition Arrearage OTHER LOAN INFORMATION: Date of the Loan Current Interest Rate $______________ $______________ $______________ $______________ $______________ $______________ Dates: ______________ $______________ Dates: ______________ $______________ $______________ $______________ $______________ $____________ _______________ _______________ Money paid to and held by the mortgagee but not applied to the loan _______________; if held in the form of checks, balance of such checks $ _______________, and identity of holder of the checks ___________________________. REQUIRED ATTACHMENTS TO MOTION: (a) In a Chapter 13 case, a postpetition payment history. (b) In all cases, copies of documents which indicate movant's interest in the subject property. For purposes of example only, a complete and legible copy of the promissory note or other debt instrument together with a complete and legible copy of the real estate mortgage should be attached. The mortgage should bear date stamps reflecting the recording date together with recording references reflecting the recordation of the mortgage with the appropriate county official. If the subject property is registered land, movant shall attach a copy of the registered land certificate or other documentation reflecting that the mortgage was memorialized as a lien on the registered land certificate. This Exhibit and Worksheet was prepared by: ___________________________________ American LegalNet, Inc. www.FormsWorkFlow.com