Forms 101A & 101B Worksheet - Eviction Judgment Statements
Worksheet only. Not the official forms. Use with the petition when a landlord has a judgment for possession and the debtor seeks to stay eviction. 101A is filed with the petition; 101B (certification) is filed after cure deposit is made.
United States Bankruptcy Court
District of [District]
In re: [Debtor Name(s)]
Case No.: [if known]
Chapter: [7/11/12/13]
Form 101A: Initial Statement About an Eviction Judgment Against You
- Do you rent your residence? [ ] Yes [ ] No
- Landlord name and address: [ ]
- Property address (rented premises): [ ]
- Was a judgment for possession entered before filing? [ ] Yes [ ] No
- Date of judgment for possession: [ ]
- Are you claiming the stay applies because you have a right to stay under nonbankruptcy law that has not expired? [ ] Yes [ ] No
- Are you depositing with the clerk any rent that will become due during the 30 days after filing? [ ] Yes [ ] No
- Amount deposited (30 days’ rent): $[ ] | Date deposited: [ ]
- Landlord service: Date you served this statement on landlord: [ ] | Method: [ ]
Debtor Signature (Form 101A)
I declare under penalty of perjury that the information provided is true and correct.
Debtor 1 Signature: __________________________ Date: __________
Debtor 2 Signature (if joint): __________________________ Date: __________
Form 101B: Certification About a Debt Secured by a Security Deposit
(Filed after the petition once rent deposit made to the clerk, if applicable.)
- Clerk’s receipt number for the rent deposit: [ ]
- Amount deposited with the clerk: $[ ]
- Date deposited: [ ]
- Statement that the debtor served a copy on the landlord: Date served [ ] | Method: [ ]
Debtor Signature (Form 101B)
I certify under penalty of perjury that the information provided in this certification is true and correct.
Debtor 1 Signature: __________________________ Date: __________
Debtor 2 Signature (if joint): __________________________ Date: __________