Official Form 10 – Fill Out and Use This PDF

Court, Name of Debtor, and Case Number:

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

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

Central District of California), the debtor’s full name, and the case number. If the

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

creditor received a notice of the case from the bankruptcy court, all of this information

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

is at the top of the notice.

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

Creditor’s Name and Address:

law limits the amount entitled to priority.

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

6. Claim Pursuant to 11 U.S.C. §503(b)(9):

the person who should receive notices issued during the bankruptcy case. A separate

Check this box if you have a claim arising from the value of any goods received by

space is provided for the payment address if it differs from the notice address. The

the Debtor within 20 days before May 14, 2012, the date of commencement of the

creditor has a continuing obligation to keep the court informed of its current address.

above case, in which the goods have been sold to the Debtor in the ordinary course of

See Federal Rule of Bankruptcy Procedure (FRBP) 2002(g).

the Debtor’s business. Attach documentation supporting such claim. (See

1. Amount of Claim as of Date Case Filed:

DEFINITIONS, below.)

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 the box if

7. Credits:

interest or other charges are included in the claim.

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

2. Basis for Claim:

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

payments received toward the debt.

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

loaned, services performed, personal injury/wrongful death, car loan, mortgage note,

8. Documents:

and credit card. If the claim is based on delivering health care goods or services, limit

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

the disclosure of the goods or services so as to avoid embarrassment or the disclosure

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

of confidential health care information. You may be required to provide additional

security interest. You may also attach a summary in addition to the documents

disclosure if an interested party objects to the claim.

themselves. FRBP 3001(c) and (d). If the claim is based on delivering health care

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

goods or services, limit disclosing confidential health care information. Do not send

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

original documents, as attachments may be destroyed after scanning.

creditor to identify the debtor.

3a. Debtor May Have Scheduled Account As:

9. Date and Signature:

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

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

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

that clarifies a difference between this proof of claim and the claim as scheduled by the

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

debtor.

penalty of perjury that the information provided is true and correct to the best of your

3b. Uniform Claim Identifier:

knowledge, information, and reasonable belief. Your signature is also a certification

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

that the claim meets the requirements of FRBP 9011(b). Whether the claim is filed

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

electronically or in person, if your name is on the signature line, you are responsible

facilitate electronic payment in chapter 13 cases.

for the declaration. Print the name and title, if any, of the creditor or other person

4. Secured Claim:

authorized to file this claim. State the filer’s address and telephone number if it

differs from the address given on the top of the form for purposes of receiving

Check whether the claim is fully or partially secured. Skip this section if the claim is

notices. If the claim is filed by an authorized agent, attach a complete copy of any

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

power of attorney, and provide both the name of the individual filing the claim and

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

the name of the agent. If the authorized agent is a servicer, identify the corporate

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

servicer as the company. Criminal penalties apply for making a false statement on a

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

proof of claim.

__________DEFINITIONS__________

______INFORMATION______

Debtor

A claim also may be secured if the creditor owes the debtor

Acknowledgment of Filing of Claim

A debtor is the person, corporation, or other entity that

money (has a right to setoff).

To receive acknowledgment of your filing, you may

has filed a bankruptcy case.

either enclose a stamped self-addressed envelope and a

Creditor

Unsecured Claim

copy of this proof of claim or you may view a list of

An unsecured claim is one that does not meet the

filed claims in this case by visiting the Claims and

A creditor is a person, corporation, or other entity to

requirements of a secured claim. A claim may be partly

Noticing Agent’s website at

whom debtor owes a debt that was incurred before the

unsecured if the amount of the claim exceeds the value of

http://www.kccllc.net/ResCap.

date of the bankruptcy filing. See 11 U.S.C. §101 (10).

the property on which the creditor has a lien.

Claim

Offers to Purchase a Claim

A claim is the creditor’s right to receive payment for a

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

Certain entities are in the business of purchasing

debt owed by the debtor on the date of the bankruptcy

Priority claims are certain categories of unsecured claims

claims for an amount less than the face value of the

filing. See 11 U.S.C. §101 (5). A claim may be secured

that are paid from the available money or property in a

claims. One or more of these entities may contact

or unsecured.

bankruptcy case before other unsecured claims.

the creditor and offer to purchase the claim. Some of

Proof of Claim

the written communications from these entities may

Redacted

easily be confused with official court documentation

A proof of claim is a form used by the creditor to

A document has been redacted when the person filing it has

or communications from the debtor. These entities

indicate the amount of the debt owed by the debtor on

masked, edited out, or otherwise deleted, certain

do not represent the bankruptcy court or the debtor.

the date of the bankruptcy filing. The creditor must file

information. A creditor must show only the last four digits

The creditor has no obligation to sell its claim.

the form with the clerk of the same bankruptcy court in

of any social-security, individual’s tax-identification, or

However, if the creditor decides to sell its claim,

which the bankruptcy case was filed.

financial-account number, only the initials of a minor’s

any transfer of such claim is subject to FRBP

Secured Claim Under 11 U.S.C. §506(a)

name, and only the year of any person’s date of birth. If the

3001(e), any applicable provisions of the

A secured claim is one backed by a lien on property of

claim is based on the delivery of health care goods or

Bankruptcy Code (11 U.S.C. § 101 et seq.), and any

the debtor. The claim is secured so long as the creditor

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

applicable orders of the bankruptcy court.

has the right to be paid from the property prior to other

to avoid embarrassment or the disclosure of confidential

creditors. The amount of the secured claim cannot

health care information.

exceed the value of the property. Any amount owed to

the creditor in excess of the value of the property is an

Evidence of Perfection

unsecured claim. Examples of liens on property include

Evidence of perfection may include a mortgage, lien,

a mortgage on real estate or a security interest in a car.

certificate of title, financing statement, or other document

A lien may be voluntarily granted by a debtor or may be

obtained through a court proceeding. In some states, a

showing that the lien has been filed or recorded.

court judgment is a lien.