Utah Form B10 – Fill Out and Use This PDF

United States Bankruptcy Court District of Utah

Proof of Claim

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" of 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

Check box if you are aware that anyone else has filed a

debtor owes money or property):

proof of claim relating to your claim. Attach copy of

statement giving particulars.

Check box if you have never received any notices from

the bankruptcy court in this case.

Name and Address Where Notices Should Be Sent

Check box if the address differs from the address on the

envelope sent to you by the bankruptcy court.

Account or other number by which creditor identifies debtor:

Check here if this claim

replaces or

amends a previous claim,

THIS SPACE IS FOR

1.

Basis for Claim

COURT USE ONLY

Goods Sold

Retiree Benefits as defined in 11 U.S.C. §1114(a)

Services Performed

Wages, Salaried, and compensations (Fill out below)

Money loaned

Your Social Security Number _______________________

Personal Injury/Wrongful Death

Unpaid compensation for services performed

Taxes

from ____________________ to ____________________

2. Date Debt Was Incurred:

3. If court judgement, date obtained:

4. Total Amount of Claim at Time Case Filed:

$ ____________________

If all or part of your claim is secured or entitled to priority, also complete Item 5 or 6 below.

Check this box is claim includes interest or other charges in addition to the principal amount of the claim. Attach itemized statement of all interest or

5.

Secured

Claim

6.

Unsecured Priority Claim

Check this box if your claim is secured by collateral (include a right of

Check this box if you have an unsecured priority claim.

setoff).

Amount entitled to priority $ ____________________

Brief Description of Collateral:

Specify the priority of the claim:

Real Estate

Motor Vehicle

Wages, Salaries, or commissions (up to $4,300)*, earned within 90

Other:

days before filing of the bankruptcy petition or cessation of the debtor's

_____________________________________________________

business, whichever is earlier. - 11 U.S.C. §507(a)(3)

Contributions to an employee benefit plan - 11 U.S.C. §507(a)(4)

Value of collateral: $______________________

Up to $1,950* of deposits toward purchase, lease, or rental of property

or services for personal, family, or household use - 11 U.S.C. §507 (a)(6)

Amount of arrearage and other charges at time case filed included in

Taxes or penalties of governmental units - 11 U.S.C. § 507(a)(7)

secured claim above, if any:

Other - Specify applicable paragraph of 11 U.S.C. §§507(a)(_____)

7.

Credits: The amount of all payments on this claim has been credited and deducted for the purpose of making this proof of

THIS SPACE IS FOR

claim.

COURT USE ONLY

8.

Supporting Documents: Attach copies of supporting documents , such as promissory notes, purchase orders, invoices,

Please mail or file this form to:

itemized statements of running accounts, contracts, court judgments, mortgages, security interests, and evidence of

U. S. BANKRUPTCY COURT

perfection of lien. DO NOT SEND ORIGINAL DOCUMENTS. If the documents are voluminous, attach a summary.

350 SOUTH MAIN STREET

SALT LAKE CITY, UT 84101

Date

Sign and print name and title, if any, of the creditor or other person authorized to file this

claim (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