Form 210a - Transfer Of Claim Other Than For Security
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Form 210A (10/06)
United States Bankruptcy Court
_______________ District Of _______________
In re ______________________________,
Case No. ________________
TRANSFER OF CLAIM OTHER THAN FOR SECURITY
A CLAIM HAS BEEN FILED IN THIS CASE or deemed filed under 11 U.S.C. § 1111(a).
Transferee hereby gives evidence and notice pursuant to Rule 3001(e)(2), Fed. R. Bankr. P., of the
transfer, other than for security, of the claim referenced in this evidence and notice.
______________________________________
____________________________________
Name of Transferee
Name of Transferor
Name and Address where notices to transferee
Court Claim # (if known):
should be sent:
Amount of Claim:
Date Claim Filed:
Phone: ______________________________
Phone:
Last Four Digits of Acct #: ______________
Last Four Digits of Acct. #: __________
Name and Address where transferee payments
should be sent (if different from above):
Phone:
Last Four Digits of Acct #:
I declare under penalty of perjury that the information provided in this notice is true and correct to the
best of my knowledge and belief.
By:__________________________________
Date:____________________________
Transferee/Transferee’s Agent
Penalty for making a false statement: Fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §§ 152 & 3571.
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