Sample Bankruptcy Claim Form

B 10 (Official Form 10) (04/10)
Name of Debtor: Case Number:
NOTE: This form should not be used to make a claim for an administrative expense arising after the commencement of the case. A request for payment of an
administrative expense may be filed pursuant to 11 U.S.C. § 503.
Name of Creditor (the person or other entity to whom the debtor owes money or property):
Check this box to indicate that this
claim amends a previously filed
Court Claim Number:______________
(If known)
Filed on:_____________________
Name and address where notices should be sent:
Telephone number:
Name and address where payment should be sent (if different from above):
Telephone number:
Check this box if you are aware that
anyone else has filed a proof of claim
relating to your claim. Attach copy of
statement giving particulars.
Check this box if you are the debtor
or trustee in this case.
1. Amount of Claim as of Dat e Case Filed: $_______________________________
If all or part of your claim is secured, complete item 4 below; however, if all of your claim is unsecured, do not complete
item 4.
If all or part of your claim is entitled to priority, complete item 5.
Check this box if claim includes interest or other charges in addition to the principal amount of claim. Attach itemized
statement of interest or charges.
5. Amount of Claim Entitled to
Priority under 11 U.S.C. §507(a). If
any portion of your claim falls in
one of the following categories,
check the box and state the
Specify the priority of the claim.
Domestic support obligations under
11 U.S.C. §507(a)(1)(A) or (a)(1)(B).
Wages, salaries, or commissions (up
to $11,725*) earned within 180 days
before filing of the bankruptcy
petition or cessation of the debtor’s
business, whichever is earlier – 11
U.S.C. §507 (a)(4).
Contributions to an employee benefit
plan – 11 U.S.C. §507 (a)(5).
Up to $2,600* of deposits toward
purchase, lease, or rental of property
or services for personal, family, or
household use – 11 U.S.C. §507
Taxes or penalties owed to
governmental units – 11 U.S.C. §507
Other – Specify applicable paragraph
of 11 U.S.C. §507 (a)(__).
Amount entitled to priority:
*Amounts are subject to adjustment on
4/1/13 and every 3 years thereafter with
respect to cases commenced on or after
the date of adjustment.
2. Basis for Claim: _____________________________
(See instruction #2 on reverse side.)
3. Last four digits of any number by which creditor identifies debtor: ______
3a. Debtor may have scheduled account as: _______________ _____
(See instruction #3a on reverse side.)
4. Secured Claim (See instruction #4 on reverse side.)
Check the appropriate box if your claim is secured by a lien on property or a right of setoff and provide the requested
Nature of property or right of setoff: Real Estate Motor Vehicle Other
Value of Property:$________________ Annual Interest Rate_________%
Amount of arrearage and other charges as of time case filed included in secured claim,
if any: $__________________ Basis for perfection: ____________________
Amount of Secured Claim: $__________________ Amount Unsecured: $__________________
6. Credits: The amount of all payments on this claim has been credited for the purpose of making this proof of claim.
7. Docum ents: Attach redacted copies of any documents that support the claim, such as promissory notes, purchase
orders, invoices, itemized statements of running accounts, contracts, judgments, mortgages, and security agreements.
You may also attach a summary. Attach redacted copies of documents providing evidence of perfection of
a security interest. You may also attach a summary. (See instruction 7 and definition of “redacted” on reverse side.)
If the documents are not available, please explain:
D Signature: The person filing this claim must sign it. Sign and print name and title, if any, of the creditor or
other person authorized to file this claim and state address and telephone number if different from the notice
address above. Attach copy of power of attorney, if any.
Penalty for presenting fraudulent claim: Fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §§ 152 and 3571.
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