Mortgage Proof Of Claim Attachment
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2B 10A (Attachment A) (12/11)
Mortgage Proof of Claim Attachment
If you file a claim secured by a security interest in the debtor’s principal residence, you must use this form as an attachment to your proof of
claim. See Bankruptcy Rule 3001(c)(2).
_______________________________________
___________________________
Name of debtor:
Case number:
Last four digits of any number you
_______________________________________
____ ____ ____ ____
Name of creditor:
use to identify the debtor’s account:
Part 1: Statement of Principal and Interest Due as of the Petition Date
Itemize the principal and interest due on the claim as of the petition date (included in the Amount of Claim listed in Item 1 on your Proof of Claim
form).
$ ____________
1. Principal due
(1)
Interest rate
From
To
Amount
2. Interest due
mm/dd/yyyy
mm/dd/yyyy
__________
_________
$ _______
_________%
__________
_________
$ _______
_________%
+
__________
_________
$ _______
_________%
►
+
$ _______
$ ____________
Total interest due as of the petition date
Copy total here
(2)
3. Total principal and
$ ____________
(3)
interest due
Part 2: Statement of Prepetition Fees, Expenses, and Charges
Itemize the fees, expenses, and charges due on the claim as of the petition date (included in the Amount of Claim listed in Item 1 on the Proof of
Claim form).
Description
Dates incurred
Amount
1. Late charges
___________________________
$ ____________
(1)
2. Non-sufficient funds (NSF) fees
___________________________
$ ____________
(2)
3. Attorney’s fees
___________________________
$ ____________
(3)
4. Filing fees and court costs
___________________________
$ ____________
(4)
5. Advertisement costs
___________________________
$ ____________
(5)
6. Sheriff/auctioneer fees
___________________________
$ ____________
(6)
7. Title costs
___________________________
$ ____________
(7)
8. Recording fees
___________________________
$ ____________
(8)
9. Appraisal/broker’s price opinion fees
___________________________
$ ____________
(9)
10. Property inspection fees
___________________________
$ ____________
(10)
11. Tax advances (non-escrow)
___________________________
$ ____________
(11)
12. Insurance advances (non-escrow)
___________________________
$ ____________
(12)
13. Escrow shortage or deficiency (Do not include amounts that are
___________________________
part of any installment payment listed in Part 3.)
$ ____________
(13)
14. Property preservation expenses. Specify:______________
___________________________
$ ____________
(14)
15. Other. Specify:_____________________________________
___________________________
$ ____________
(15)
16. Other. Specify:_____________________________________
___________________________
$ ____________
(16)
17. Other. Specify:_____________________________________
___________________________
+ $ ____________
(17)
18. Total prepetition fees, expenses, and charges. Add all of the amounts listed above.
$ ____________
(18)
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