Form 106d -Schedule D: Creditors Who Have Claims Secured By Property (Page 2 of 3) in pdf

_______________________________________________________

Case number

_____________________________________

Debtor 1

(if known)

First Name

Middle Name

Last Name

Additional Page

Column A

Column B

Column C

Part 1:

Amount of claim

Value of collateral

Unsecured

After listing any entries on this page, number them beginning with 2.3, followed

that supports this

portion

Do not deduct the

by 2.4, and so forth.

claim

value of collateral.

If any

Describe the property that secures the claim:

$_________________ $________________ $____________

______________________________________

Creditor’s Name

______________________________________

Number

Street

______________________________________

As of the date you file, the claim is:

Check all that apply.



Contingent

______________________________________



City

State

ZIP Code

Unliquidated



Disputed

Who owes the debt?

Check one.

Nature of lien

. Check all that apply.



Debtor 1 only

An agreement you made (such as mortgage or secured



car loan)

Debtor 2 only



Statutory lien (such as tax lien, mechanic’s lien)

Debtor 1 and Debtor 2 only



Judgment lien from a lawsuit

At least one of the debtors and another



Other (including a right to offset) ____________________



Check if this claim relates to a

community debt

Date debt was incurred ____________

Last 4 digits of account number ___ ___ ___ ___

Describe the property that secures the claim:

$_________________ $________________ $____________

______________________________________

Creditor’s Name

______________________________________

Number

Street

As of the date you file, the claim is:

Check all that apply.

______________________________________



Contingent



Unliquidated

______________________________________



City

State

ZIP Code

Disputed

Who owes the debt?

Check one.

Nature of lien

. Check all that apply.



Debtor 1 only



An agreement you made (such as mortgage or secured



Debtor 2 only

car loan)



Debtor 1 and Debtor 2 only

Statutory lien (such as tax lien, mechanic’s lien)



At least one of the debtors and another

Judgment lien from a lawsuit



Other (including a right to offset) ____________________



Check if this claim relates to a

community debt

Date debt was incurred ____________

Last 4 digits of account number ___ ___ ___ ___

Describe the property that secures the claim:

$_________________ $________________ $____________

______________________________________

Creditor’s Name

______________________________________

Number

Street

______________________________________

As of the date you file, the claim is:

Check all that apply.



Contingent

______________________________________



City

State

ZIP Code

Unliquidated



Disputed

Who owes the debt?

Check one.

Nature of lien

. Check all that apply.



Debtor 1 only

An agreement you made (such as mortgage or secured



car loan)

Debtor 2 only



Statutory lien (such as tax lien, mechanic’s lien)

Debtor 1 and Debtor 2 only



Judgment lien from a lawsuit

At least one of the debtors and another



Other (including a right to offset) ____________________



Check if this claim relates to a

community debt

Date debt was incurred ____________

Last 4 digits of account number ___ ___ ___ ___

Add the dollar value of your entries in Column A on this page. Write that number here:

$_________________

If this is the last page of your form, add the dollar value totals from all pages.

$_________________

Write that number here:

Official Form 106D

Additional Page of Schedule D: Creditors Who Have Claims Secured by Property

page ___ of ___

Form 106d -Schedule D: Creditors Who Have Claims Secured By Property Page 2

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