Fillable Printable Bankruptcy Proof of Claim Form
Fillable Printable Bankruptcy Proof of Claim Form
Bankruptcy Proof of Claim Form
B10 (Official Form 10) (04/13)
UNITED STATES BANKRUPTCY COURT __________ District of __________
PROOF OF CLAIM
Name of Debtor:
Case Number:
COURT USE ONLY
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):
Name and address where notices should be sent:
Telephone number: email:
❐ Check this box if this claim amends a
previously filed claim.
Court Claim Number:______________
(If known)
Filed on:_____________________
Name and address where payment should be sent (if different from above):
Telephone number: email:
❐ Check this box if you are aware that
anyone else has filed a proof of claim
relating to this claim. Attach copy of
statement giving par ticulars.
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, com plete 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
by which creditor identifies debtor:
___ ___ ___ ___
3a. Debtor m ay have scheduled account as:
_____________________________
(See instruction #3a)
3b. Uniform Claim Identifier (optional):
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
(See instruction #3b)
4. Secured Claim (See instr uction #4)
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
Describe:
Value of Property: $________________
Annual Interest Rate_______% ❐Fixed
or ❐Variable
(when case was filed)
Am ount of arrearage and other charges, as of the time case was filed,
included in secured claim, if any:
$__________________
Basis for perfection: ________________ _______________________
Am ount of Secured Claim: $__________________
Am ount Unsecured: $__________________
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
U.S.C. § 507 ( a)(1)(A) or (a )(1)(B).
❐ Wages, salaries, or commissions (up to $12,475*)
earned within 180 days before the case was filed or the
debtor’s business ceased, whichever is earlier –
11 U.S.C. § 507 (a)(4).
❐ Contributions to an
employee benefit plan –
11 U.S.C. § 507 (a)(5).
Amount entitled to priority:
$______________________
❐ Up to $2,775* of deposits toward
purchase, lease, or rental of pr operty or
services for personal, family, or household
use – 11 U.S.C. § 507 (a) (7).
❐ Taxes or penalties owed to governmental units –
11 U.S.C. § 507 (a)(8).
❐ Other – Specify
applicable paragraph of
11 U.S.C. § 507 (a)(__).
*Amounts are subject to adjustment on 4/01/16 and every 3 years thereafter with respect to cases commenced on or after the date of adjustment.
6. Credits. The amount of all payments on this claim has been credited for the purpose of making this proof of claim. (See instruction #6)
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7. Documents: Attached are redacted copies of any documents that support the claim, such as promissory notes, purchase orders, invoices, itemized statements of
running accounts, contracts, judgments, m ortgages, security agreements, or, in the case of a claim based on an open-end or revolving consumer credit agreement, a
statement providing the information requir e d by FRBP 3001(c)(3)(A). If the claim is secured, box 4 has been completed, and redacted copies of documents providing
evidence of perfection of a security interest are attached. If the claim is secured by the debtor's principal residence, the Mortgage Proof of Claim Attachment is being
filed with this claim. (See instruction #7, and the definition of “redacted”.)
DO NOT SEND ORIGINAL DOCUMENTS. ATTACHED DOCUMENTS MAY BE DESTROYED AFTER SCANNING.
If the documents are not available, please explain:
8. Signature: (See instruction #8)
Check the appropriate box.
❐ I am the creditor.
❐ I am the creditor’s authorized agent. ❐ I am the trustee, or the debtor,
or their authorized agent.
(See Bankruptcy Rule 3004.)
❐ I am a guarantor, surety, indorser, or other codebtor.
(See Bankruptcy Rule 3005.)
I declare under penalty of perjury that the information provided in this cl aim is true and correct to the best of my knowledge, information, and reasonable belief.
Print Name: _________________________________________________
Title: __________________________ _______________________
Company: ___________________ _____________ ____________ _____
Address and telephone num ber ( i f different from notice address above):
_________________________________________________
_________________________________________________
_________________________________________________
Telephone number: email:
(Signature) (Date)
Penalty for presenting fraudulent claim: Fine of up to $500,000 or impr isonment for up to 5 years, or both. 18 U.S.C. §§ 152 and 3571.
INSTRUCTIONS FOR PROOF OF CLAIM FORM
The instructions and definitions below are general explanations of the law. In certain circumstances, such as bankruptcy cases not filed voluntarily by the debtor,
exceptions to these general rules may apply.
Items to be completed in Proof of Claim form
Court, Name of Debtor, and Case Number:
Fill in the federal judicial district in which the bankruptcy case was filed (for
example, Central District of California), the debtor’s full name, and the case
number. If the creditor received a notice of the case from the bankruptcy court,
all of this information is at the top of the notice.
Creditor’s Name and Address:
Fill in the name of the person or entity asserting a claim and the name and
address of the person who should receive notices issued during the bankruptcy
case. A separate space is provided for the payment address if it differs from the
notice address. The creditor has a continuing obligation to keep the court
informed of its current address. See Federal Rule of Bankruptcy Procedure
(FRBP) 2002(g).
1. Am ount of Claim as of Date Case Filed:
State the total amount owed to the creditor on the date of the bankruptcy filing.
Follow the instructions concerning whether to complete items 4 and 5. Check
the box if interest or other charges are included in the claim.
2. Basis for Claim:
State the type of debt or how it was incurred. Examples include goods sold,
money loaned, services performe d, personal injury/wrongful death, car loan,
mortgage note, and credit card. If the claim is based on delivering health care
goods or services, limit the disclosure of the goods or services so as to avoid
embarrassment or the disclosure of confidential health care information. You
may be require d to provide additional disclosure if an interested party objects to
the claim.
3. Last Four Digits of Any Number by Which Creditor Identifies Debtor:
State only the last four digits of the debtor’s account or other number used by the
creditor to identify the debtor.
3a. Debtor May Have Scheduled Account As:
Report a change in the creditor’s name, a transferred claim, or any other
information that clarifies a difference between this proof of claim and the claim
as scheduled by the debtor.
3b. Uniform Claim Identifier:
If you use a uniform claim identifier , you may report it here. A uniform claim
identifier is an optional 24-character identifier that certain large creditors use to
facilitate electronic payment in chapter 13 cases.
4. Secured Claim:
Check whether the claim is fully or partially secured. Skip this section if the
claim is entirely unsecured. (See Definitions.) If the claim is secured, check the
box for the nature and value of property that secures the claim, attach copies of lien
documentation, and state, as of the date of the bankruptcy filing, the annual interest
rate (and whether it is fixed or variable), and the amount past due on the claim.
5. Am ount of Claim Entitled to Priority Under 11 U.S.C. § 507 (a).
If any portion of the claim falls into any category shown, check the appropriate
box(es) and state the amount entitled to priority. (See Definitions.) A claim may
be partly priority and partly non-priority. For example, in some of the categories,
the law limits the amount entitled to priority.
6. Credits:
An authorized signature on this pr oof of claim serves as an acknowledgment that
when calculating the amount of the claim, the creditor gave the debtor credit for
any payments received toward the debt.
7. Documents:
Attach redacted copies of any docum ents that show the debt exists and a lien
secures the debt. You must also attach copies of documents that evidence perfection
of any security interest
and documents requir ed by FRBP 3001(c) for claims based
on an open-end or re volving consumer credit agreement or secured by a security
interest in the debtor’s principal residence. You may also attach a summary in
addition to the documents themselves. FRBP 3001(c) and (d). If the claim is based
on delivering health care goods or services, limit disclosing confidential health car e
information. Do not send original documents, as attachments may be destroyed
after scanning.
8. Date and Signature:
The individual completing this proof of claim must sign and date it. FRBP 9011.
If the claim is filed electronically, FRBP 5005(a)(2) authorizes courts to establish
local rules specifying what constitutes a signature. If you sign this form, you
declare under penalty of perjury that the information provided is true and correct to
the best of your knowledge, information, and reasonable belief. Your signature is
also a certification that the claim meets the requirements of FRBP 9011(b).
Whether the claim is filed electronically or in person, if your name is on the
signature line, you are responsible for the declaration. Print the name and title, if
any, of the creditor or other person authorized to file this claim. State the filer’s
address and telephone number if it differs from the address given on the top of the
form for purposes of receiving notices. If the claim is filed by an authorized agent,
provide both the name of the individual filing the claim and the name of the agent.
If the authorized agent is a servicer, identify the corporate servicer as the co mpany.
Criminal penalties apply for making a false statement on a proof of claim.
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__________DEFINITIONS__________ ______INFORMATION______
Debtor
A debtor is the person, corpor ation, or other entity
that has filed a bankruptcy case.
Creditor
A creditor is a person, corporation, or other entity to
whom debtor owes a debt that was incurred before
the date of the bankruptcy filing. See 11 U.S.C.
§101 (10).
Claim
A claim is the creditor’s right to receive payment for
a debt owed by the debtor on the date of the
bankruptcy filing. See 11 U.S.C. §101 (5). A claim
may be secured or unsecured.
Proof of Claim
A proof of claim is a form used by the creditor to
indicate the amount of the debt owed by the debtor
on the date of the bankruptcy filing. The creditor
must file the form with the clerk of the same
bankruptcy court in which the bankr uptcy case was
filed.
Secured Claim Under 11 U.S.C. § 506 (a)
A secured claim is one backed by a lien on property
of the debtor. The claim is secured so long as the
creditor has the right to be paid from the propert y
prior to other creditors. The am ount of the secured
claim cannot exceed the value of the propert y. Any
amount owed to the cr editor in excess of the value of
the property is an unsecured claim. Examples of
liens on property include a mortgage on real estate or
a security interest in a car. A lien may be voluntarily
granted by a debtor or may be obtained through a
court proceeding. In some states, a court judgment is
a lien.
A claim also may be secured if the creditor owes the
debtor money (has a right to setoff).
Unsecured Claim
An unsecured claim is one that does not meet the
requirements of a secured claim . A claim may be
partly unsecured if the amount of the claim exceeds
the value of the property on which the creditor has a
lien.
Claim Entitled to Priority Under 11 U.S.C. § 507
(a)
Priority claims are certain categories of unsecured
claims that are paid from the available money or
property in a bankruptcy case before other unsecured
claims.
Redacted
A document has been redacted when the person filing
it has masked, edited out, or otherw ise deleted,
certain information. A creditor must show only the
last four digits of any social-security, individual’s
tax-identification, or financial-account number, only
the initials of a minor’s name, and only the year of
any person’s date of birth. If the claim is based on the
delivery of health care goods or services, limit the
disclosure of the goods or services so as to avoid
embarrassment or the disclosure of confidential
health care information.
Evidence of Perfection
Evidence of perfection may include a mortgage, lien,
certificate of title, financing statement, or other
document showing that the lien has been filed or
recorded.
Acknowledgment of Filing of Claim
To receive acknowledgment of your filing, you may
either enclose a stamped self-addressed envelope and
a copy of this proof of claim or you may access the
court’s PACER system
(www.pacer.psc.uscourts.gov) for a small fee to view
your filed pr oof of claim.
Offers to Purchase a Claim
Certain entities are in the business of purchasing
claims for an amount less than the face value of the
claims. One or more of these entities may contact the
creditor and offer to purchase the claim. Some of the
written communications from these entities may
easily be confused with official court documentation
or communications from the debtor. These entities
do not represent the bankr uptcy court or the debtor.
The creditor has no obligation to sell its claim.
However, if the creditor decides to sell its claim, any
transfer of such claim is subject to FRBP 3001(e),
any applicable provisions of the Bankruptcy Code
(11 U.S.C. § 101 et seq.), and any applicable orders
of the bankruptcy court.
