UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF VIRGINIA OFFICE OF THE CLERK Date of Request ______________________________ Name of Requestor_____________________________ Case Name__________________________________ Address______________________________________ Case No.____________________________________ _____________________________________________ AP No. ____________________________________ Telephone No.(____)____________________________ Request for Certified Copies or Government Agency Photocopies Check one: _____Certified Copies. Identify document(s) $9.00 per document plus $ .50 per page copy fee ______ Search to be certified: ______________________________ Fee - $26.00 if request made other than in person For the above items, make check payable to Clerk, U.S. Bankruptcy Court. Amount Due $________________________ The above document requests are normally completed and available for pickup after 10:00 a.m. the next business day following the date of request. Please indicate at the bottom of this form your preferred method for receiving these documents upon completion of your request by the Clerk’s Office. [PHOTOCOPY REQUESTS FOR GOVERNMENT AGENCIES ONLY: Will be processed within two business days following request] Document Description Date Filed Entry Number Number of Pages Petition Schedules Statement of Financial Affairs 341 Meeting Notice Discharge No Distribution Report Chapter 13 Plan _______To be mailed. A self-addressed, stamped envelope of adequate size is attached to this request. _______To be picked up at the Clerk's Office. Requests not picked up within 10 days will be destroyed. FOR OFFICE USE ONLY: Date Requestor Notified:____________________________ Amount Paid: _____________ Date Paid:________________ Date Mailed/Picked Up:_____________________________ If picked up at Clerk’s Office: Date Received: __________ Signature of Requestor/Agent:___________________________ [req4docr ver. 6/1/05] American LegalNet, Inc. www.USCourtForms.com