Official Form 410 - Proof Of Claim - United States Bankruptcy Court Page 2
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Give Information About the Claim as of the Date the Case Was Filed
6. Do you have any number
No
you use to identify the
Yes. Last 4 digits of the debtor’s account or any number you use to identify the debtor: ____ ____ ____ ____
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
Examples: Goods sold, money loaned, lease, services performed, personal injury or wrongful death, or credit card.
claim?
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
No
secured?
Yes. The claim is secured by a lien on property.
Nature of property:
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
No
lease?
Yes. Amount necessary to cure any default as of the date of the petition.
$____________________
11. Is this claim subject to a
No
right of setoff?
Yes. Identify the property: ___________________________________________________________________
Official Form 410
Proof of Claim
page 2
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