Official Form 410 - Proof Of Claim Page 3
ADVERTISEMENT
1
2
3
4
512. Is all or part of the claim
No
entitled to priority under
Amount entitled to priority
11 U.S.C. § 507(a)?
Yes. Check all that apply:
A claim may be partly
Domestic support obligations (including alimony and child support) under
priority and partly
11 U.S.C. § 507(a)(1)(A) or (a)(1)(B).
$
nonpriority. For example,
in some categories, the
Up to $2,850* of deposits toward purchase, lease, or rental of property or
law limits the amount
services for personal, family, or household use. 11 U.S.C. § 507(a)(7).
$
entitled to priority.
Wages, salaries, or commissions (up to $12,850*) 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 4/01/19 and every 3 years after that for cases begun on or after the date of adjustment.
13. Is all or part of the claim
No
pursuant to 11 U.S.C.
§ 503(b)(9)?
Yes. Indicate the amount of your claim arising from the value of any goods received by the debtor within 20
days before the date of commencement of the above case, in which the goods have been sold to the Debtor in
the ordinary course of such Debtor’s business. Attach documentation supporting such claim.
$
Part 3:
Sign Below
The person completing
Check the appropriate box:
this proof of claim must
sign and date it.
I am the creditor.
FRBP 9011(b).
I am the creditor’s attorney or authorized agent.
If you file this claim
electronically, FRBP
I am the trustee, or the debtor, or their authorized agent. Bankruptcy Rule 3004.
5005(a)(2) authorizes courts
to establish local rules
I am a guarantor, surety, endorser, or other codebtor. Bankruptcy Rule 3005.
specifying what a signature
is.
I understand that an authorized signature on this Proof of Claim serves as an acknowledgement that when calculating
the 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 reasonable belief that the information is true and correct.
fined up to $500,000,
imprisoned for up to 5
I declare under penalty of perjury that the foregoing is true and correct.
years, or both.
18 U.S.C. §§ 152, 157, and
Executed on date
3571.
MM / DD / YYYY
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
Country
Contact phone
Email
Official Form 410
Proof of Claim
page 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal