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Case 22-10871-MAM Doc 10 Filed 02/04/22 Page 9 of 10
Official Form 101A Initial Statement About an Eviction Judgment Against You

Official Form 101A 

Initial Statement About an Eviction Judgment Against You 12/15

File this form with the court and serve a copy on your landlord when you first file bankruptcy only if:

 you rent your residence; and

 your landlord has obtained a judgment for possession in an eviction, unlawful detainer action, or

similar proceeding (called eviction judgment) against you to possess your residence.

Landlord’s name __________________________________________________ 

Landlord’s address __________________________________________________

Number Street 

_______________________________ _________ ___________ 

City State ZIP Code 

If you want to stay in your rented residence after you file your case for bankruptcy, also complete the certification below. 

Certification About Applicable Law and Deposit of Rent 

I certify under penalty of perjury that:

 Under the state or other nonbankruptcy law that applies to the judgment for possession (eviction judgment),

I have the right to stay in my residence by paying my landlord the entire delinquent amount.

 I have given the bankruptcy court clerk a deposit for the rent that would be due during the 30 days after I file

the Voluntary Petition for Individuals Filing for Bankruptcy (Official Form 101).

8____________________________________________ 8____________________________________________

Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________

MM / DD / YYYY MM / DD / YYYY

Stay of Eviction: (a) First 30 days after bankruptcy. If you checked both boxes above, signed the form to certify that both apply, 

and served your landlord with a copy of this statement, the automatic stay under 11 U.S.C. § 362(a)(3) will 

apply to the continuation of the eviction against you for 30 days after you file your Voluntary Petition for 

Individuals Filing for Bankruptcy (Official Form 101).

(b) Stay after the initial 30 days. If you wish to stay in your residence after that 30-day period and continue to

receive the protection of the automatic stay under 11 U.S.C. § 362(a)(3), you must pay the entire delinquent

amount to your landlord as stated in the eviction judgment before the 30-day period ends. You must also fill

out Statement About Payment of an Eviction Judgment Against You (Official Form 101B), file it with the

bankruptcy court, and serve your landlord a copy of it before the 30-day period ends.

Check the Bankruptcy Rules ( http://www.uscourts.gov/rules-policies/current-rules-practice-procedure) and the local court’s website (to find 

your court’s website, go to http://www.uscourts.gov/court-locator) for any specific requirements that you might have to meet to serve this 

statement. 11 U.S.C. §§ 362(b)(22) and 362(l) 

Debtor 1 ________________________________________________________________

First Name Middle Name Last Name

Debtor 2 ________________________________________________________________

(Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: __________________ District of ____________ (State)

Case number ___________________________________________

(If known)

Fill in this information to identify your case:

Brett

Southern Florida

Allen Elam

22-10871-MAM

ARC Financial Group, Inc.

/s/ Brett Allen Elam

2/4/2022

515 N. Flagler Drive, Ste. P-300

West Palm Beach FL 33401

Case 22-10871-MAM Doc 10 Filed 02/04/22 Page 10 of 10