Fillable Official Form 104 For Individual Chapter 11 Cases: (US Courts)

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Official Form 104 For Individual Chapter 11 Cases: (US Courts)

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Official Form 104 For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims
page 1
Official Form 104
For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest
Unsecured Claims Against You and Are Not Insiders
12/15
If you are an individual filing for bankruptcy under Chapter 11, you must fill out this form. If you are filing under Chapter 7, Chapter 12, or
Chapter 13, do not fill out this form. Do not include claims by anyone who is an insider. Insiders include your relatives; any general partners;
relatives of any general partners; partnerships of which you are a general partner; corporations of which you are an officer, director, person in
control, or owner of 20 percent or more of their voting securities; and any managing agent, including one for a business you operate as a sole
proprietor. 11 U.S.C. § 101. Also, do not include claims by secured creditors unless the unsecured claim resulting from inadequate collateral
value places the creditor among the holders of the 20 largest unsecured claims.
Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct
information.
Part 1: List the 20 Unsecured Claims in Order from Largest to Smallest. Do Not Include Claims by Insiders.
Unsecured claim
1
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security:
- $_____________________
Unsecured claim $_____________________
2
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security: - $_____________________
Unsecured claim $_____________________
Debtor 1 __________________________________________________________________
First Name Middle Name Last Name
Debtor 2 ________________________________________________________________
(Spouse, if filing) First Name Middle Name Last Name
United States Bankruptcy Court for the: __________ District of __________
Case number ___________________________________________
(If known)
Fill in this information to identify your case:
Check if this is an
amended filing
__________ District of __________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
page 2
Unsecured claim
3
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security:
- $_____________________
Unsecured claim $_____________________
4
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security:
- $_____________________
Unsecured claim $_____________________
5
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security:
- $_____________________
Unsecured claim $_____________________
6
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security:
- $_____________________
Unsecured claim $_____________________
7
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security: - $_____________________
Unsecured claim $_____________________
Official Form 104 For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
page 3
Unsecured claim
8
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security:
- $_____________________
Unsecured claim $_____________________
9
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security:
- $_____________________
Unsecured claim $_____________________
10
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security:
- $_____________________
Unsecured claim $_____________________
11
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security:
- $_____________________
Unsecured claim $_____________________
12
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security: - $_____________________
Unsecured claim $_____________________
Official Form 104 For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Official Form 104 For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims
page 4
Unsecured claim
13
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security:
- $_____________________
Unsecured claim $_____________________
14
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security:
- $_____________________
Unsecured claim $_____________________
15
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security:
- $_____________________
Unsecured claim $_____________________
16
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security:
- $_____________________
Unsecured claim $_____________________
17
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security: - $_____________________
Unsecured claim $_____________________
Debtor 1 _______________________________________________________ Case number (if known)_____________________________________
First Name Middle Name Last Name
Offic
ial Form 104 For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 5
Unsecured claim
18
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security:
- $_____________________
Unsecured claim $_____________________
19
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security:
- $_____________________
Unsecured claim $_____________________
20
__________________________________________
Creditor’s Name
__________________________________________
Number Street
__________________________________________
__________________________________________
City State ZIP Code
__________________________________________
Contact
____________________________________
Contact phone
What is the nature of the claim? ____________________________
$____________________________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
None of the above apply
Does the creditor have a lien on your property?
No
Yes. Total claim (secured and unsecured): $_____________________
Value of security: - $_____________________
Unsecured claim $_____________________
Part 2: Sign Below
Under penalty of perjury, I declare that the information provided in this form is true and correct.
______________________________________________ ______________________________________________
Signature of Debtor 1 Signature of Debtor 2
Date
_________________ Date _________________
MM / DD / YYYY MM / DD / YYYY
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Official Form 104 For Individual Chapter 11 Cases: (US Courts)

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Completed 24 September 2021

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