NOTICE OF APPEAL AND STATEMENT OF ELECTION

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

Official Form 417A (12/23)

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

Part 1: Identify the appellant(s)

Name(s) of appellant(s):

_ _ _

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

Describe the judgment—or the appealable order or decree—from which the appeal is taken:

State the date on which the judgment—or the appealable order or decree—was entered:

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):

Party: _ __ Attorney:

_ _ _

Party: _ __ Attorney:

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.

[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.]