B10 (Official Form 10) (04/13)
UNITED STATES BANKRUPTCY COURT __________ District of __________
PROOF OF CLAIM
Name of Debtor:
COURT USE ONLY
NOTE: Do not use this form to make a claim for an administrative expense that arises after the bankruptcy filing. You
may file a request for payment of an administrative expense according to 11 U.S.C. § 503.
Name of Creditor (the person or other entity to whom the debtor owes money or property):
Name and address where notices should be sent:
Telephone number: email:
❐ Check this box if this claim amends a
previously filed claim.
Court Claim Number:______________
Name and address where payment should be sent (if different from above):
Telephone number: email:
❐ Check this box if you are aware that
anyone else has filed a proof of claim
relating to this claim. Attach copy of
statement giving par ticulars.
1. Amount of Claim as of Date Case Filed: $_______________________________
If all or part of the claim is secured, complete item 4.
If all or part of the claim is entitled to priority, com plete item 5.
❐Check this box if the claim includes interest or other charges in addition to the principal amount of the claim. Attach a statement that itemizes interest or charges.
2. Basis for Claim: _____________________________________ ____________ ____________ ____
(See instruction #2)
3. Last four digits of any number
by which creditor identifies debtor:
___ ___ ___ ___
3a. Debtor m ay have scheduled account as:
(See instruction #3a)
3b. Uniform Claim Identifier (optional):
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
(See instruction #3b)
4. Secured Claim (See instr uction #4)
Check the appropriate box if the claim is secured by a lien on property or a right of
setoff, attach required redacted documents, and provide the requested information.
Nature of property or right of setoff: ❐Real Estate ❐Motor Vehicle ❐Other
Value of Property: $________________
Annual Interest Rate_______% ❐Fixed
(when case was filed)
Am ount of arrearage and other charges, as of the time case was filed,
included in secured claim, if any:
Basis for perfection: ________________ _______________________
Am ount of Secured Claim: $__________________
Am ount Unsecured: $__________________
5. Amount of Claim Entitled to Priority under 11 U.S.C. § 507 (a). If any part of the claim falls into one of the following categories, check the box specifying
the priority and state the amount.
❐ Domestic support obligations under 11
U.S.C. § 507 ( a)(1)(A) or (a )(1)(B).
❐ Wages, salaries, or commissions (up to $12,475*)
earned within 180 days before the case was filed or the
debtor’s business ceased, whichever is earlier –
11 U.S.C. § 507 (a)(4).
❐ Contributions to an
employee benefit plan –
11 U.S.C. § 507 (a)(5).
Amount entitled to priority:
❐ Up to $2,775* of deposits toward
purchase, lease, or rental of pr operty or
services for personal, family, or household
use – 11 U.S.C. § 507 (a) (7).
❐ Taxes or penalties owed to governmental units –
11 U.S.C. § 507 (a)(8).
❐ Other – Specify
applicable paragraph of
11 U.S.C. § 507 (a)(__).
*Amounts are subject to adjustment on 4/01/16 and every 3 years thereafter with respect to cases commenced on or after the date of adjustment.
6. Credits. The amount of all payments on this claim has been credited for the purpose of making this proof of claim. (See instruction #6)