Official Form 417A (12/15)

Official Form 417A Notice of Appeal and Statement of Election page 1 

[Caption as in Form 416A, 416B, or 416D, as appropriate] 

 NOTICE OF APPEAL AND STATEMENT OF ELECTION 

Part 1: Identify the appellant(s) 

1. Name(s) of appellant(s): 

_________________________________________________________________________ 

2. Position of appellant(s) in the adversary proceeding or bankruptcy case that is the subject of this 

appeal: 

For appeals in an adversary proceeding. 

 Plaintiff 

 Defendant 

 Other (describe) ________________________

For appeals in a bankruptcy case and not in an 

adversary proceeding. 

 Debtor 

 Creditor 

 Trustee 

 Other (describe) ________________________

Part 2: Identify the subject of this appeal 

1. Describe the judgment, order, or decree appealed from: ____________________________ 

2. State the date on which the judgment, order, or decree was entered: ___________________ 

Part 3: Identify the other parties to the appeal 

List the names of all parties to the judgment, order, or decree appealed from and the names, addresses, 

and telephone numbers of their attorneys (attach additional pages if necessary): 

1. Party: _________________ Attorney: ______________________________ 

 ______________________________ 

 ______________________________ 

 ______________________________ 

2. Party: _________________ Attorney: ______________________________ 

 ______________________________ 

 ______________________________ 

 ______________________________ 

Tyrone A. Conard & Joyce L. Conard

✔

Summary Judgment against plaintiff, Tyrone A. Conard

12/14/2017

Internal Revenue Service Nelson D. Wagner

US Department of Justice, Tax Division

PO Box 227

Washington, DC 20044

(202) 616-3369

Case 16-01121-KHK Doc 71 Filed 08/02/18 Entered 08/02/18 14:10:06 Desc Main

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Official Form 417A Notice of Appeal and Statement of Election page 2 

Part 4: Optional election to have appeal heard by District Court (applicable only in 

certain districts)

If a Bankruptcy Appellate Panel is available in this judicial district, the Bankruptcy Appellate Panel will 

hear this appeal unless, pursuant to 28 U.S.C. § 158(c)(1), a party elects to have the appeal heard by the 

United States District Court. If an appellant filing this notice wishes to have the appeal heard by the 

United States District Court, check below. Do not check the box if the appellant wishes the Bankruptcy 

Appellate Panel to hear the appeal. 

 Appellant(s) elect to have the appeal heard by the United States District Court rather than by 

the Bankruptcy Appellate Panel. 

Part 5: Sign below 

_____________________________________________________ Date: ____________________________ 

Signature of attorney for appellant(s) (or appellant(s) 

if not represented by an attorney) 

Name, address, and telephone number of attorney 

(or appellant(s) if not represented by an attorney): 

_____________________________________________________ 

_____________________________________________________ 

_____________________________________________________ 

_____________________________________________________ 

Fee waiver notice: If appellant is a child support creditor or its representative and appellant has filed the 

form specified in § 304(g) of the Bankruptcy Reform Act of 1994, no fee is required.

✔

/s/ Robert R. Weed July 16, 2018

Robert R. Weed, VSB #24646

1376 Old Bridge Rd., Ste. 101-4

Woodbridge, VA 22192

(703) 335-7793

Case 16-01121-KHK Doc 71 Filed 08/02/18 Entered 08/02/18 14:10:06 Desc Main

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