Fillable B 10, 2012, Proof Of Claim (Page 2 of 3) in pdf

B 10 (Official Form 10) (12/12)

7. Documents: Attached are redacted copies of any documents that support the claim, such as promissory notes, purchase orders, invoices, itemized statements of

running accounts, contracts, judgments, mortgages, security agreements, or, in the case of a claim based on an open-end or revolving consumer credit agreement, a

statement providing the information required by FRBP 3001(c)(3)(A). If the claim is secured, box 4 has been completed, and redacted copies of documents providing

evidence of perfection of a security interest are attached. If the claim is secured by the debtor's principal residence, the Mortgage Proof of Claim Attachment is being

filed with this claim. (See instruction #7, and the definition of “redacted”.)

DO NOT SEND ORIGINAL DOCUMENTS. ATTACHED DOCUMENTS MAY BE DESTROYED AFTER SCANNING.

If the documents are not available, please explain:

8. Signature: (See instruction #8)

Check the appropriate box.

❐ 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.)

I declare under penalty of perjury that the information provided in this claim is true and correct to the best of my knowledge, information, and reasonable belief.

Print Name: _________________________________________________

Title:

_________________________________________________

Company:

_________________________________________________

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

(Signature)

(Date)

_________________________________________________

Telephone number:

email:

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.

INSTRUCTIONS FOR PROOF OF CLAIM FORM

The instructions and definitions below are general explanations of the law. In certain circumstances, such as bankruptcy cases not filed voluntarily by the debtor,

exceptions to these general rules may apply.

Items to be completed in Proof of Claim form

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

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

2. Basis for Claim:

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

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

3b. Uniform Claim Identifier:

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.

4. Secured Claim:

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

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