CACB — Notice of Appeal and Statement of Election (417A)

Source: https://www.cacb.uscourts.gov/sites/cacb/files/documents/forms/417A.pdf

Attorney or Party Name, Address, Telephone & FAX FOR COURT USE ONLY Nos., State Bar No. & Email Address

Individual appearing without attorney
Attorney for:

UNITED STATES BANKRUPTCY COURT
CENTRAL DISTRICT OF CALIFORNIA - SELECTSELECTSELECT DIVISIONDIVISIONDIVISION DIVISION

In re: CASE NO.: ADVERSARY NO.: (if applicable) CHAPTER: Select Chapter Debtor(s).

Plaintiff(s) (if applicable).
NOTICE OF APPEAL vs.
AND STATEMENT OF ELECTION

Defendant(s) (if applicable).

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):

July 2026 Page 1 Official Form 417A

Part 2: Identify the subject of this appeal

1. ☐ The order or judgment is entered on the court docket AND a copy of the entered order or judgment is attached to this Notice of Appeal. a. Date of entry of the order or judgment: _______________ b. Docket entry number of the order or judgment: _______________ c. Title in caption of order or judgment: _________________________________________________________ ______________________________________________________________________________________

2. ☐ The order or judgment is not entered on the court docket: a. Date of the hearing at which the court issued a ruling in court: _______________ b. Title in caption of the motion or adversary proceeding complaint on which the court issued a ruling: ________

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Part 3: Identify the other parties to the appeal

List the names of all parties to the judgment—or the appealable order or decree—from which the appeal is taken and the names, addresses, and telephone numbers of their attorneys (attach additional pages if necessary):

1. Party:

   Attorney:

2. Party:

   Attorney:

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)

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.

[Note to inmate filers: If you are an inmate filer in an institution and you seek the timing benefit of Fed. R. Bankr. P. 8002(c)(1), complete Director’s Form 4170 (Declaration of Inmate Filing) and file that declaration along with the Notice of Appeal.]

July 2026 Page 2 Official Form 417A

PROOF OF SERVICE OF DOCUMENT

I am over the age of 18 and not a party to this bankruptcy case or adversary proceeding. My business address is:

A true and correct copy of the foregoing document entitled: NOTICE OF APPEAL AND STATEMENT OF ELECTION will be served or was served (a) on the judge in chambers in the form and manner required by LBR 5005-2(d); and (b) in the manner stated below:

1. TO BE SERVED BY THE COURT VIA NOTICE OF ELECTRONIC FILING (NEF): Pursuant to controlling General Orders and LBR, the foregoing document will be served by the court via NEF and hyperlink to the document. On (date) , I checked the CM/ECF docket for this bankruptcy case or adversary proceeding and determined that the

following persons are on the Electronic Mail Notice List to receive NEF transmission at the email addresses stated below:

Service information continued on attached page

2. SERVED BY UNITED STATES MAIL: On (date) , I served the following persons and/or entities at the last known addresses in this bankruptcy case or adversary proceeding by placing a true and correct copy thereof in a sealed envelope in the United States mail, first class, postage prepaid, and addressed as follows. Listing the judge here constitutes a declaration that mailing to the judge will be completed no later than 24 hours after the document is filed.

   Service information continued on attached page

3. SERVED BY PERSONAL DELIVERY, OVERNIGHT MAIL, FACSIMILE TRANSMISSION OR EMAIL (state method for each person or entity served): Pursuant to F.R.Civ.P. 5 and/or controlling LBR, on (date) , I served the following persons and/or entities by personal delivery, overnight mail service, or (for those who consented in writing to such service method), by facsimile transmission and/or email as follows. Listing the judge here constitutes a declaration that personal delivery on, or overnight mail to, the judge will be completed no later than 24 hours after the document is filed.

   Service information continued on attached page

I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct.

Date Printed Name Signature

July 2026 Page 3 Official Form 417A