Official Form 417A "Notice of Appeal and Statement of Election"

What Is Official Form 417A?

This is a legal form that was released by the United States Bankruptcy Court on December 1, 2018 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2018;
  • The latest available edition released by the United States Bankruptcy Court;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Official Form 417A by clicking the link below or browse more documents and templates provided by the United States Bankruptcy Court.

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Download Official Form 417A "Notice of Appeal and Statement of Election"

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Official Form 417A (12/18)
[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.
For appeals in a bankruptcy case and not in an
adversary proceeding.
Plaintiff
Defendant
Debtor
Other (describe) ________________________
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: ______________________________
______________________________
______________________________
______________________________
Official Form 417A
Notice of Appeal and Statement of Election
page 1
Official Form 417A (12/18)
[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.
For appeals in a bankruptcy case and not in an
adversary proceeding.
Plaintiff
Defendant
Debtor
Other (describe) ________________________
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: ______________________________
______________________________
______________________________
______________________________
Official Form 417A
Notice of Appeal and Statement of Election
page 1
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.
[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.]
Official Form 417A
Notice of Appeal and Statement of Election
page 2
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