Official Form 410 - Proof Of Claim - United States Bankruptcy Court Page 3
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12. Is all or part of the claim
No
entitled to priority under
Yes. Check all that apply:
Amount entitled to priority
11 U.S.C. § 507(a)?
Domestic support obligations (including alimony and child support) under
A claim may be partly
$____________________
11 U.S.C. § 507(a)(1)(A) or (a)(1)(B).
priority and partly
nonpriority. For example,
Up to $2,775* of deposits toward purchase, lease, or rental of property or services for
in some categories, the
$____________________
personal, family, or household use. 11 U.S.C. § 507(a)(7).
law limits the amount
entitled to priority.
Wages, salaries, or commissions (up to $12,475*) 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 4/01/16 and every 3 years after that for cases begun on or after the date of adjustment.
Part 3:
Sign Below
The person completing
Check the appropriate box:
this proof of claim must
I am the creditor.
sign and date it.
FRBP 9011(b).
I am the creditor’s attorney or authorized agent.
If you file this claim
I am the trustee, or the debtor, or their authorized agent. Bankruptcy Rule 3004.
electronically, FRBP
I am a guarantor, surety, endorser, or other codebtor. Bankruptcy Rule 3005.
5005(a)(2) authorizes courts
to establish local rules
specifying what a signature
I understand that an authorized signature on this Proof of Claim serves as an acknowledgment that when calculating the
is.
amount of the claim, the creditor gave the debtor credit for any payments received toward the debt.
A person who files a
fraudulent claim could be
I have examined the information in this Proof of Claim and have a reasonable belief that the information is true
fined up to $500,000,
and correct.
imprisoned for up to 5
years, or both.
I declare under penalty of perjury that the foregoing is true and correct.
18 U.S.C. §§ 152, 157, and
3571.
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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Official Form 410
Proof of Claim
page 3
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