Bankruptcy B10 Proof Of Claim Form – Fill Out and Use This PDF

UNITED STATES BANKRUPTCY COURT

__________ District of __________

PROOF OF CLAIM

Name of Debtor:

Case Number:

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):

COURT USE ONLY

Name and address where notices should be sent:

❐ Check this box if this claim amends a

previously filed claim.

Court Claim Number:______________

(If known)

Telephone number:

email:

Filed on:_____________________

Name and address where payment should be sent (if different from above):

❐ 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 particulars.

Telephone number:

email:

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, complete item 5.

3. Last four digits of any number

3a. Debtor may have scheduled account as:

3b. Uniform Claim Identifier (optional):

by which creditor identifies debtor:

_____________________________

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

___ ___ ___ ___

(See instruction #3a)

(See instruction #3b)

Amount of arrearage and other charges, as of the time case was filed,

4. Secured Claim (See instruction #4)

included in secured claim, if any:

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

Basis for perfection: _______________________________________

Describe:

Value of Property: $________________

Amount of Secured Claim:

$__________________

Annual Interest Rate_______% ❐Fixed

or ❐Variable

Amount Unsecured:

$__________________

(when case was filed)

❐ Domestic support obligations under 11

❐ Wages, salaries, or commissions (up to $12,475*)

❐ Contributions to an

U.S.C. § 507 (a)(1)(A) or (a)(1)(B).

earned within 180 days before the case was filed or the

employee benefit plan –

debtor’s business ceased, whichever is earlier –

11 U.S.C. § 507 (a)(5).

11 U.S.C. § 507 (a)(4).

Amount entitled to priority:

❐ Up to $2,775* of deposits toward

❐ Taxes or penalties owed to governmental units –

❐ Other – Specify

$______________________

purchase, lease, or rental of property or

11 U.S.C. § 507 (a)(8).

applicable paragraph of

services for personal, family, or household

11 U.S.C. § 507 (a)(__).

use – 11 U.S.C. § 507 (a)(7).

B10 (Official Form 10) (04/13)

2

❐ I am the creditor.

❐ I am the creditor’s authorized agent.

❐ I am the trustee, or the debtor,

❐ I am a guarantor, surety, indorser, or other codebtor.

or their authorized agent.

(See Bankruptcy Rule 3005.)

(See Bankruptcy Rule 3004.)

Address and telephone number (if different from notice address above):

(Signature)

(Date)

_________________________________________________

_________________________________________________

_________________________________________________

Court, Name of Debtor, and Case Number:

claim is entirely unsecured. (See Definitions.) If the claim is secured, check the

Fill in the federal judicial district in which the bankruptcy case was filed (for

box for the nature and value of property that secures the claim, attach copies of lien

example, Central District of California), the debtor’s full name, and the case

documentation, and state, as of the date of the bankruptcy filing, the annual interest

number. If the creditor received a notice of the case from the bankruptcy court,

rate (and whether it is fixed or variable), and the amount past due on the claim.

all of this information is at the top of the notice.

5. Amount of Claim Entitled to Priority Under 11 U.S.C. § 507 (a).

Creditor’s Name and Address:

If any portion of the claim falls into any category shown, check the appropriate

Fill in the name of the person or entity asserting a claim and the name and

box(es) and state the amount entitled to priority. (See Definitions.) A claim may

address of the person who should receive notices issued during the bankruptcy

be partly priority and partly non-priority. For example, in some of the categories,

case. A separate space is provided for the payment address if it differs from the

the law limits the amount entitled to priority.

notice address. The creditor has a continuing obligation to keep the court

informed of its current address. See Federal Rule of Bankruptcy Procedure

6.

Credits:

(FRBP) 2002(g).

An authorized signature on this proof of claim serves as an acknowledgment that

when calculating the amount of the claim, the creditor gave the debtor credit for

1. Amount of Claim as of Date Case Filed:

any payments received toward the debt.

State the total amount owed to the creditor on the date of the bankruptcy filing.

Follow the instructions concerning whether to complete items 4 and 5. Check

7.

Documents:

the box if interest or other charges are included in the claim.

Attach redacted copies of any documents that show the debt exists and a lien

secures the debt. You must also attach copies of documents that evidence perfection

2. Basis for Claim:

of any security interest and documents required by FRBP 3001(c) for claims based

State the type of debt or how it was incurred. Examples include goods sold,

on an open-end or revolving consumer credit agreement or secured by a security

money loaned, services performed, personal injury/wrongful death, car loan,

interest in the debtor’s principal residence. You may also attach a summary in

mortgage note, and credit card. If the claim is based on delivering health care

addition to the documents themselves. FRBP 3001(c) and (d). If the claim is based

goods or services, limit the disclosure of the goods or services so as to avoid

on delivering health care goods or services, limit disclosing confidential health care

embarrassment or the disclosure of confidential health care information. You

information. Do not send original documents, as attachments may be destroyed

may be required to provide additional disclosure if an interested party objects to

after scanning.

the claim.

8.

Date and Signature:

3. Last Four Digits of Any Number by Which Creditor Identifies Debtor:

The individual completing this proof of claim must sign and date it. FRBP 9011.

State only the last four digits of the debtor’s account or other number used by the

If the claim is filed electronically, FRBP 5005(a)(2) authorizes courts to establish

creditor to identify the debtor.

local rules specifying what constitutes a signature. If you sign this form, you

declare under penalty of perjury that the information provided is true and correct to

3a. Debtor May Have Scheduled Account As:

the best of your knowledge, information, and reasonable belief. Your signature is

Report a change in the creditor’s name, a transferred claim, or any other

also a certification that the claim meets the requirements of FRBP 9011(b).

information that clarifies a difference between this proof of claim and the claim

Whether the claim is filed electronically or in person, if your name is on the

as scheduled by the debtor.

signature line, you are responsible for the declaration. Print the name and title, if

any, of the creditor or other person authorized to file this claim. State the filer’s

3b. Uniform Claim Identifier:

address and telephone number if it differs from the address given on the top of the

If you use a uniform claim identifier, you may report it here. A uniform claim

form for purposes of receiving notices. If the claim is filed by an authorized agent,

identifier is an optional 24-character identifier that certain large creditors use to

provide both the name of the individual filing the claim and the name of the agent.

facilitate electronic payment in chapter 13 cases.

If the authorized agent is a servicer, identify the corporate servicer as the company.

Criminal penalties apply for making a false statement on a proof of claim.