Fillable Proof of Claim 04/19 (US Courts)

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Proof of Claim 04/19 (US Courts)

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Official Form 410 Proof of Claim page 1
Official Form 410
Proof of Claim 04/19
Read the instructions before filling out this form. This form is for making a claim for payment in a bankruptcy case. Do not use this form to
make a request for payment of an administrative expense. Make such a request according to 11 U.S.C. § 503.
Filers must leave out or redact information that is entitled to privacy on this form or on any attached documents. 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. Do not send original documents; they may be destroyed after scanning. If the documents are not available,
explain in an attachment.
A person who files a fraudulent claim could be fined up to $500,000, imprisoned for up to 5 years, or both. 18 U.S.C. §§ 152, 157, and 3571.
Fill in all the information about the claim as of the date the case was filed. That date is on the notice of bankruptcy (Form 309) that you received.
Part 1: Identify the Claim
1. Who is the current
creditor?
___________________________________________________________________________________________________________
Name of the current creditor (the person or entity to be paid for this claim)
Other names the creditor used with the debtor ________________________________________________________________________
2. Has this claim been
acquired from
someone else?
No
Yes. From whom? ______________________________________________________________________________________________________
3. Where should notices
and payments to the
creditor be sent
?
Federal Rule of
Bankruptcy Procedure
(FRBP) 2002(g)
Where should notices to the creditor be sent? Where should payments to the creditor be sent? (if
different)
_____________________________________________________
Name
______________________________________________________
Number Street
______________________________________________________
City State ZIP Code
Contact phone
________________________
Contact email ________________________
_____________________________________________________
Name
______________________________________________________
Number Street
______________________________________________________
City State
ZIP Code
Contact phone
________________________
Contact email ________________________
Uniform claim identifier for electronic payments in chapter 13 (if you use one):
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
4. Does this claim amend
one already filed?
No
Yes. Claim number on court claims registry (if known) ________ Filed on ________________________
MM / DD / YYYY
5. Do you know if anyone
else has filed a proof
of claim for this claim?
No
Yes. Who made the earlier filing? _____________________________
Debtor 1 __________________________________________________________________
Debtor 2 ________________________________________________________________
(Spouse, if filing)
United States Bankruptcy Court for the:
__________ District of __________
Case number ___________________________________________
Fill in this information to identify the case:
__________ District of __________
Official Form 410 Proof of Claim page 2
Part 2: Give Information About the Claim as of the Date the Case Was Filed
6. D
o you have any number
you use to identify th
e
debt
or?
No
Yes. Last 4 digits of the debtor’s account or any number you use to identify the debtor: ____ ____ ____ ____
7. How much is the claim? $_____________________________. Does this amount include interest or other charges?
No
Yes. Attach statement itemizing interest, fees, expenses, or other
charges
required by Bankruptcy Rule 3001(c)(2)(A).
8. What is the basis of the
claim?
Examples: Goods sold, money loaned, lease, services performed, personal injury or wrongful death, or credit card.
Attach redacted copies of any documents supporting the claim required by Bankruptcy Rule 3001(c).
Limit disclosing information that is entitled to privacy, such as health care information.
______________________________________________________________________________
9. Is all or part of the claim
secured?
No
Yes. The claim is secured by a lien on property.
Nature of prop
erty:
Real estate. If the claim is secured by the debtor’s principal residence, file a Mortgage Proof of Claim
Attachment (Official Form 410-A) with this Proof of Claim.
Motor vehicle
Other. Describe: _____________________________________________________________
Basis for perfection: _____________________________________________________________
Attach redacted copies of documents, if any, that show evidence of perfection of a security interest (for
example, a mortgage, lien, certificate of title, financing statement, or other document that shows the lien has
been filed or recorded.)
Value of property: $__________________
Amount of the claim that is secured: $__________________
Amount of the claim that is unsecured: $__________________ (The sum of the secured and unsecured
amounts should match the amount in line 7.)
Amount necessary to cure any default as of the date of the petition: $____________________
Annual Interest Rate (when case was filed) _______%
Fixed
Variable
10. Is this claim based on a
lease?
No
Yes. Amount necessary to cure any default as of the date of the petition. $____________________
11. Is this claim subject to a
right of setoff?
No
Yes. Identify the property: ___________________________________________________________________
Official Form 410 Proof of Claim page 3
12. Is all or part of the claim
entitled to priority under
11 U.S.C. § 507(a)?
A claim may be partly
priority and partly
nonpriority. For example,
in some categories, the
law limits the amount
entitled to priority.
Amount entitled to priority
$________
____________
$____________________
$____________________
$____________________
$____________________
No
Yes. Check one:
Domestic support obligations (including alimony and child support) under
11 U.S.C. § 507(a)(1)(A) or (a)(1)(B).
Up to $3,025* of deposits toward purchase, lease, or rental of property or services for
personal, family, or household use. 11 U.S.C. § 507(a)(7).
Wages, salaries, or commissions (up to $13,650*) earned within 180 days before the
bankruptcy petition is filed or the debtor’s business ends, whichever is earlier.
11 U.S.C. § 507(a)(4).
Taxes or penalties owed to governmental units. 11 U.S.C. § 507(a)(8).
Contributions to an employee benefit plan. 11 U.S.C. § 507(a)(5).
Other. Specify subsection of 11 U.S.C. § 507(a)(__) that applies.
$____________________
* Amounts are subject to adjustment on 4/01/22 and every 3 years after that for cases begun on or after the date of adjustment.
Part 3: Sign Below
The person completing
this proof of claim must
sign and date it.
FRBP 9011(b).
If you file this claim
electronically, FRBP
5005(a)(2) authorizes courts
to establish local rules
specifying what a signature
is.
A person who files a
fraudulent claim could be
fined up to $500,000,
imprisoned for up to 5
years, or both.
18 U.S.C. §§ 152, 157, and
3571.
Check the appropriate box:
I am the creditor.
I am the creditor’s attorney or authorized agent.
I am the trustee, or the debtor, or their authorized agent. Bankruptcy Rule 3004.
I am a guarantor, surety, endorser, or other codebtor. Bankruptcy Rule 3005.
I understand that 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 any payments received toward the debt.
I have examined the information in this Proof of Claim and have a reasonable belief that the information is true
and correct.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on
date _________________
MM / DD / YYYY
8________________________________________________________________________
Signature
Print the name of the person who is completing and signing this claim:
Name _______________________________________________________________________________________________
First name Middle name Last name
Title _______________________________________________________________________________________________
Company
_______________________________________________________________________________________________
Identify the corporate servicer as the company if the authorized agent is a servicer.
Address
_______________________________________________________________________________________________
Number Street
_______________________________________________________________________________________________
City State ZIP Code
Contact phone
_____________________________ Email ____________________________________
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Proof of Claim 0419 (US Courts)

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Completed 8 December 2020

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