UNITED STATES BANKRUPTCY COURT DISTRICT OF OREGON In re Debtor(s) ) ) ) ) ) Case No. ________________ (If Known) INDIVIDUAL DEBTOR'S* STATEMENT OF INTENTION(S) PER 11 U.S.C. §521(a) *IMPORTANT NOTICES TO DEBTOR(S): (1) SIGN AND FILE this form even if you show "NONE," AND, if creditors are listed, have the service certificate COMPLETED; AND (2) Failure to perform the intentions as to property stated below within 30 days after the first date set for the Meeting of Creditors under 11 USC §341(a) may result in relief for the creditor from the Automatic Stay protecting such property. PROPERTY TO BE RETAINED (CHECK ANY APPLICABLE STATEMENT) CREDITOR/LESSOR DESCRIPTION OF SECURED OR LEASED PROPERTY I/WE, THE UNDERSIGNED DEBTOR(S), CERTIFY THAT THE ABOVE INDICATES MY/OUR INTENTION AS TO ANY PROPERTY LISTED IN MY SCHEDULES THAT IS ESTATE PROPERTY SECURING A DEBT AND/OR PERSONAL PROPERTY SUBJECT TO AN UNEXPIRED LEASE. DATE: __________ ____________________________________________________________ DEBTOR’S SIGNATURE ____________________________________________________________ JOINT DEBTOR’S SIGNATURE (If applicable) PROPERTY PROPERTY WILL BE SURRENDERED IS CLAIMED AS EXEMPT PROPERTY WILL BE REDEEMED PER 11 USC §722 PROPERTY LEASE TO BE WILL BE ASSUMED PER REAFFIRMED 11 USC PER 11 USC §362(h)(1) §524(c) I/WE THE UNDERSIGNED, CERTIFY THAT COPIES OF BOTH THIS DOCUMENT AND LOCAL FORM #715 WERE SERVED ON ANY CREDITOR NAMED ABOVE. DATE: __________ ____________________________________________________________ DEBTOR OR ATTORNEY’S SIGNATURE OSB# (if attorney) _____________________________________________________________ JOINT DEBTOR’S SIGNATURE (If applicable and no attorney) ____________________________________________________________ PRINT OR TYPE SIGNER’S NAME & PHONE NO. ____________________________________________________________ SIGNER’S ADDRESS (if attorney) ____________________________________________________________ NON-JUDICIAL REMEDY WHEN CONSUMER DEBTOR FAILS TO TIMELY PERFORM STATED INTENTIONS Creditors, see Local Form #715 [attached if this document was served on paper] if you wish information on how to obtain NON-JUDICIAL relief from the automatic stay of 11 U.S.C. §362(a) as to your collateral. QUESTIONS???? Call an attorney with questions about these procedures or the law. However, only call the debtor's attorney if you have questions about the debtor's intent as to your collateral. 521.05 (12/18/06) American LegalNet, Inc. www.FormsWorkflow.com