UNITED STATES COURT OF APPEALS

COVER SHEET FOR DIRECT APPEAL OF A BANKRUPTCY COURT DECISION

Case Caption [caption as described in Fed. R. Bankr. P. 7010 or 9004(b), as applicable]:

Bankruptcy Court Case No:

Bankruptcy Adversary Proceeding No. [if applicable]:

District Court Civil No. [if applicable]:

Bankruptcy Judge:

District Judge [if applicable]:

Date and Document Number of Notice of Appeal Filed in [ ] Adversary Proceeding or [ ] Bankruptcy Case:	Date and Document Number of Bankruptcy Court Judgment, Order or Decree in [ ] Adversary Proceeding or [ ] Bankruptcy Case:

[To answer questions below, place "X" on lines where appropriate:]

1. Who is certifying the direct appeal?

___Certification by Court (indicate below which court is certifying)

___Certification by Bankruptcy Court – district: __________

___Certification by District Court – district: _________

___ At request of one or more parties

___ On court's own initiative

___ Court is required to make certification under 28 U.S.C. § 158(d)(2)(B)

___Certification by All Parties using Official Form 24 – district from which appeal is taken: ______

2. Which paragraph of section 158(a) is applicable [28 U.S.C. § 158(a)]?

___28 U.S.C. § 158(a)(1): appeal of a final judgment, order or decree

___28 U.S.C. § 158(a)(2): appeal of an interlocutory order or decree issued under 11 U.S.C. § 1121(d)

___28 U.S.C. § 158(a)(3): appeal of an interlocutory order or decree [other than one issued under 11 U.S.C. § 1121(d)] requiring leave of the court [indicate below whether leave has been granted]

___ District Court has not yet granted leave

___ District Court has already granted leave [provide civil proceeding name and civil number, date of order, name of judge, etc., in space provided below]

___________________________________________________________________________

3. Indicate basis for direct appeal [select one of the following]:

___ The judgment, order or decree involves a question of law as to which there is no controlling decision of the court of appeals for this circuit or of the Supreme Court of the United States, or involves a matter of public importance.

___ The judgment, order or decree involves a question of law requiring resolution of conflicting decisions.

___ An immediate appeal from the judgment, order or decree may materially advance the progress of the case or proceeding in which the appeal is taken.

4. Indicate whether appellant has obtained a stay pending appeal and provide pertinent information pertaining to stay (date of issuance, etc.):

Granted	______ Yes	______ No	Date and Court of Issuance:_________________________________

5. Provide below a brief description of the matter decided by the bankruptcy judge [example: Order Confirming Chapter 11 Plan]: ______________________________________________________________________________

6. Bankruptcy Judge: __________________________________________________________________

[For notifying bankruptcy judges, staff of the court of appeals should refer to the circuit clerk's list of e-mail addresses.]

Date: ____________	Submitted by:	________________________________

Name

________________________________

Title/Firm or Court