Fillable Bankruptcy Proof Of Claim Form 2013 printable pdf download

B10 (Official Form 10) (04/13)

PROOF OF CLAIM

NITED

TATES

ANKRUPTCY

OURT

__________ District of __________

Name of Debtor:

Case Number:

NOTE: Do not use this form to make a claim for an administrative expense that arises after the bankruptcy filing. You

may file a request for payment of an administrative expense according to 11 U.S.C. § 503.

Name of Creditor (the person or other entity to whom the debtor owes money or property):

COURT USE ONLY

❐ Check this box if this claim amends a

Name and address where notices should be sent:

previously filed claim.

Court Claim Number:______________

(If known)

Telephone number:

email:

Filed on:_____________________

❐ Check this box if you are aware that

Name and address where payment should be sent (if different from above):

anyone else has filed a proof of claim

relating to this claim. Attach copy of

statement giving particulars.

Telephone number:

email:

1. Amount of Claim as of Date Case Filed:

$_______________________________

If all or part of the claim is secured, complete item 4.

If all or part of the claim is entitled to priority, complete item 5.

❐Check this box if the claim includes interest or other charges in addition to the principal amount of the claim. Attach a statement that itemizes interest or charges.

2. Basis for Claim: _________________________________________________________________

(See instruction #2)

3. Last four digits of any number

3a. Debtor may have scheduled account as:

3b. Uniform Claim Identifier (optional):

by which creditor identifies debtor:

_____________________________

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

___ ___ ___ ___

(See instruction #3a)

(See instruction #3b)

Amount of arrearage and other charges, as of the time case was filed,

4. Secured Claim (See instruction #4)

included in secured claim, if any:

Check the appropriate box if the claim is secured by a lien on property or a right of

setoff, attach required redacted documents, and provide the requested information.

$__________________

Nature of property or right of setoff: ❐Real Estate ❐Motor Vehicle ❐Other

Basis for perfection: _______________________________________

Describe:

Amount of Secured Claim:

$__________________

Value of Property: $________________

Amount Unsecured:

$__________________

Annual Interest Rate_______% ❐Fixed or ❐Variable

(when case was filed)

5. Amount of Claim Entitled to Priority under 11 U.S.C. § 507 (a). If any part of the claim falls into one of the following categories, check the box specifying

the priority and state the amount.

❐ Domestic support obligations under 11

❐ Wages, salaries, or commissions (up to $12,475*)

❐ Contributions to an

U.S.C. § 507 (a)(1)(A) or (a)(1)(B).

earned within 180 days before the case was filed or the

employee benefit plan –

debtor’s business ceased, whichever is earlier –

11 U.S.C. § 507 (a)(5).

Amount entitled to priority:

11 U.S.C. § 507 (a)(4).

$______________________