Rev. 09/01/14 LOCAL BANKRUPTCY FORM 4001-1 IN THE UNITED STATES BANKRUPTCY COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA IN RE: : : : : : : CHAPTER 13 CASE NO. - -bk- Debtor(s) POST-PETITION PAYMENT HISTORY NOTE AND MORTGAGE DATED Recorded on __________, in ___________________ County, at ________________________ . Property Address: __________________________________________________________________ Mortgage Servicer: __________________________________________________________________ Post-petition mailing address for Debtor(s) to send payment: __________________________________________________________________ Mortgagor(s)/Debtor(s): ____________________________________________________________ Payments are contractually due: Monthly____ Semi-monthly_____ Bi-weekly______ Other _______________ Each Monthly Payment is comprised of: Principal and Interest....... ____________________ R.E. Taxes...................... ____________________ Insurance........................ ____________________ Late Charge.................... ____________________ Other.............................. ____________________ (Specify: ______________________) TOTAL......................... ____________________ POST-PETITION PAYMENTS (Petition was filed on ________________) American LegalNet, Inc. www.FormsWorkFlow.com Rev. 09/01/14 Payment amount due Date payment was due Date payment was received Amount received Check number How payment was applied (mo./yr.) [Continue on attached sheets if necessary] TOTAL NUMBER OF POST-PETITION PAYMENTS PAST DUE: _____________as of _________________. TOTAL AMOUNT OF POST-PETITION ARREARS: _______________ as of _______________. Dated: _________________ ______________________________ Mortgage Company ______________________________ (Print Name and Title) (2) American LegalNet, Inc. www.FormsWorkFlow.com