UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF VIRGINIA In re: DEBTOR(S) MOVANTS NAME CASE NO. CHAPTER: MOVANT(S) v. RESPONDENTS NAME AND TRUSTEE RESPONDENT(S) MOVANT'S CERTIFICATION REQUIRED WITH RESPECT TO MOTION FOR RELIEF FROM STAY 1. Description of Property:______________________________________________________________________ 2. Copies of Security Instruments: Attached as Movant's Exhibit No. 1. 3. Statement of Amount Due: (a) Unpaid Principal: __________________________________________________________________ (b) Accrued Interest from a specific date to a specific date: ____________________________________ ____________________________________________________________________________________ (c) Late Charges from a specific date to a specific date: _______________________________________ _____________________________________________________________________________________ (d) Attorney's fees: ____________________________________________________________________ (e) Advances for Taxes, Insurance, and the Like: ____________________________________________ (f) Unearned Interest: __________________________________________________________________ (g) Any Other Charges: ________________________________________________________________ 4. A Per Diem Interest Factor: __________________________________________________________________ 5. Movant's valuation of property: $____________ Basis of such valuation:_______________________________________________________________________ Appraisal or other documentation of such valuation, if attached, is identified as Movant's Exhibit No. 2. I HEREBY CERTIFY, as a Member of the Bar of the Court, that I represent the above-named Movant(s) and that the information contained herein is true according to the best of my knowledge and belief. DATED:_______________________ ___________________________________ Signature of Movant's Attorney ***ALL BLANKS MUST BE COMPLETED. IF THE ANSWER IS NONE OR NOT APPLICABLE, PLEASE SO STATE. American LegalNet, Inc. www.FormsWorkFlow.com