UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF RHODE ISLAND ------------------------------* In re: : : Debtor(s) : ------------------------------* R.I. Local Form 4001-1.1 BK No. Chapter RELIEF FROM STAY WORKSHEET ­ REAL ESTATE I (Name and Title) of (Name of Organization/ Corporation/Moving Party) (hereinafter, "Movant") hereby declare (or certify, verify, or state): BACKGROUND INFORMATION 1. Real property address which is the subject of this motion: . 2. Lender Name: 3. Date of Mortgage: 4. Post-Petition payment address: . 5. The manner in which the movant perfected its interest in the property: . 6. All other material liens and encumbrances on the property: . . . DEBT/VALUE REPRESENTATIONS 7. Total pre-petition and post-petition indebtedness of Debtor(s) to Movant at the time of filing the motion: $ . (Note: this amount may not be relied on as a "payoff" quotation.) 8. Movant's estimated market value of the real property: $ . 19 American LegalNet, Inc. www.FormsWorkFlow.com 9. Source of estimated valuation: . STATUS OF DEBT AS OF THE PETITION DATE 10. Total pre-petition indebtedness of Debtor(s) to Movant as of petition filing date: $ . A. B. C. D. E. F. Amount of principal: $ . Amount of interest: $ . Amount of escrow (taxes and insurance): $ . Amount of forced placed insurance expended by Movant: Amount of Attorney's fees billed to Debtor(s) pre-petition: $ Amount of pre-petition late fees, if any, billed to Debtor(s): $ . . . 11. Contractual interest rate: (If interest rate is (or was) adjustable, please list the rate(s) and dates(s) the rate(s) was/were in effect on a separate sheet and attach the sheet as an exhibit to this form; please list the exhibit number here: .) 12. Please explain any additional pre-petition fees, charges or amounts charged to Debtor's/Debtor's account and not listed above: . (If additional space is needed, please list the amounts on a separate sheet and attach the sheet as an exhibit to this form; please list the exhibit number here: .) AMOUNT OF ALLEGED POST-PETITION DEFAULT (AS OF (MM/DD/YYYY) 13. Date last payment was received: (mm/dd/yyyy) 14. Alleged total number of payments post-petition from filing of petition through payment due on (mm/dd/yyyy): . 20 American LegalNet, Inc. www.FormsWorkFlow.com 15. Please list all post-petition payments alleged to be in default: SCHEDULE OF PAYMENTS THAT WERE DUE: Date Payment Due Payment Amount Due Post Petition Totals: $ SCHEDULE OF PAYMENTS THAT WERE RECEIVED Date Amount Received Amount Applied to Principal and Interest Amount Applied to Escrow Late Fee Charged (if any) Amount applied to legal fees or costs (specify) Totals: $ $ $ $ 16. Amount of Movant's Attorneys fees billed to Debtor for the preparation, filing and prosecution of this motion: $ . 17. Amount of Movant's filing fee for this motion: $ 18. Other Attorney's fees billed to Debtor post-petition: $ 19. Amount of Movant's post-petition inspection fees: $ 21 American LegalNet, Inc. www.FormsWorkFlow.com . . . 20. Amount of Movant's post-petition appraisal/broker's price opinion: $ . 21. Amount of forced placed insurance or insurance provided by the Movant post-petition: $ . 22. Sum held in suspense by Movant in connection with this contract, if applicable: $ . 23. Amount of other post-petition advances or charges: i.e., taxes, insurance incurred by Debtor, etc.: $ . 24. Amount and date of post-petition payments offered by the debtor and refused by the Movant: $ ; Date(s): Movant: $ Movant: $ ; ; Date(s): Date(s): . REQUIRED ATTACHMENTS TO MOTION Please attach the following documents to this motion and indicate the exhibit number associated with the documents. (1) Copies of documents that 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 mortgage and any assignments in the chain from the original mortgagee to the current moving party. (Exhibit .) Copies of documents establishing proof of standing to bring this Motion. (Exhibit .) Copies of documents establishing that Movant's interest in the real property was perfected. For the purposes of example only, a complete and legible copy of the Financing Statement (UCC-1) filed with either the Clerk's Office or the Register of the county the property is located in. (Exhibit .) (2) (3) 22 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION AND DECLARATION FOR BUSINESS RECORDS I certify that the information provided in this worksheet and/or exhibits attached to this worksheet is derived from records that were made at or near the time of the occurrence of the matters set forth by, or from information transmitted by, a person with knowledge of those matters, were kept in the course of the regularly conducted activity; and were made by the regularly conducted activity as a regular practice. I further certify that copies of any transactional documents attached to this worksheet as required by paragraphs 1, 2, and 3, immediately above, are true and accurate copies of the original documents, I further certify that the original documents are in movant's possession, except as follows: . I/we declare (or certify, swear, affirm, verify or state) that the foregoing is true and correct. Executed on [date] [signature] [title] Subscribed and sworn to before me this [date] Notary Public:[name] My commission Expires: [date] 23 American LegalNet, Inc. www.FormsWorkFlow.com