Fillable Printable Sample Bankruptcy Claim Form
Fillable Printable Sample Bankruptcy Claim Form
Sample Bankruptcy Claim Form
B 10 (Official Form 10) (04/10)
UNITED STATES BANKRUPTCY COURT __________ DISTRICT OF __________
PROOF OF CLAIM
Name of Debtor: Case Number:
NOTE: This form should not be used to make a claim for an administrative expense arising after the commencement of the case. A request for payment of an
administrative expense may be filed pursuant to 11 U.S.C. § 503.
Name of Creditor (the person or other entity to whom the debtor owes money or property):
Check this box to indicate that this
claim amends a previously filed
claim.
Court Claim Number:______________
(If known)
Filed on:_____________________
Name and address where notices should be sent:
Telephone number:
Name and address where payment should be sent (if different from above):
Telephone number:
Check this box if you are aware that
anyone else has filed a proof of claim
relating to your claim. Attach copy of
statement giving particulars.
Check this box if you are the debtor
or trustee in this case.
1. Amount of Claim as of Dat e Case Filed: $_______________________________
If all or part of your claim is secured, complete item 4 below; however, if all of your claim is unsecured, do not complete
item 4.
If all or part of your claim is entitled to priority, complete item 5.
Check this box if claim includes interest or other charges in addition to the principal amount of claim. Attach itemized
statement of interest or charges.
5. Amount of Claim Entitled to
Priority under 11 U.S.C. §507(a). If
any portion of your claim falls in
one of the following categories,
check the box and state the
amount.
Specify the priority of the claim.
Domestic support obligations under
11 U.S.C. §507(a)(1)(A) or (a)(1)(B).
Wages, salaries, or commissions (up
to $11,725*) earned within 180 days
before filing of the bankruptcy
petition or cessation of the debtor’s
business, whichever is earlier – 11
U.S.C. §507 (a)(4).
Contributions to an employee benefit
plan – 11 U.S.C. §507 (a)(5).
Up to $2,600* of deposits toward
purchase, lease, or rental of property
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)(__).
Amount entitled to priority:
$_______________
*Amounts are subject to adjustment on
4/1/13 and every 3 years thereafter with
respect to cases commenced on or after
the date of adjustment.
2. Basis for Claim: _____________________________
(See instruction #2 on reverse side.)
3. Last four digits of any number by which creditor identifies debtor: ______
3a. Debtor may have scheduled account as: _______________ _____
(See instruction #3a on reverse side.)
4. Secured Claim (See instruction #4 on reverse side.)
Check the appropriate box if your claim is secured by a lien on property or a right of setoff and provide the requested
information.
Nature of property or right of setoff: Real Estate Motor Vehicle Other
Describe:
Value of Property:$________________ Annual Interest Rate_________%
Amount of arrearage and other charges as of time case filed included in secured claim,
if any: $__________________ Basis for perfection: ____________________
Amount of Secured Claim: $__________________ Amount Unsecured: $__________________
6. Credits: The amount of all payments on this claim has been credited for the purpose of making this proof of claim.
7. Docum ents: Attach redacted copies of any documents that support the claim, such as promissory notes, purchase
orders, invoices, itemized statements of running accounts, contracts, judgments, mortgages, and security agreements.
You may also attach a summary. Attach redacted copies of documents providing evidence of perfection of
a security interest. You may also attach a summary. (See instruction 7 and definition of “redacted” on reverse side.)
DO NOT SEND ORIGINAL DOCUMENTS. ATTACHED DOCUMENTS MAY BE DESTROYED AFTER
SCANNING.
If the documents are not available, please explain:
D Signature: The person filing this claim must sign it. Sign and print name and title, if any, of the creditor or
other person authorized to file this claim and state address and telephone number if different from the notice
address above. Attach copy of power of attorney, if any.
FOR COURT USE ONLY
Penalty for presenting fraudulent claim: Fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §§ 152 and 3571.
Date:
B 10 (Official Form 10) (04/10) – Cont.
INSTRUCTIONS FOR PROOF OF CLAIM FORM
The instructions and definitions below are general explanatio ns of the law. In certain circumstances, such as bankruptcy cases not filed voluntarily by the debtor, there
may be exceptions to these general rules.
Items to be completed in Proof of Claim form
Court, Name of Debtor, and Case Number:
Fill in the federal judicial district where the bankruptcy case was filed (for
example, Central District of California), the bankruptcy debtor’s name, and the
bankruptcy case number. If the creditor received a notice of the case from the
bankruptcy court, all of this information is located 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. Amount of Claim as of Dat e 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 performed, personal
injury/wrongful death, car loan, mortgage note, and credit card. 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. You may be required
to provide additional disclosure if the trustee or another party in interest
files an objection to your 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:
Use this space to 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.
4. Secured Claim:
Check the appropriate box and provide the requested information if
the claim is fully or partially secured. Skip this section if the claim is
entirely unsecured. (See DEFINITIONS, below.) State the type and
the value of property that secures the claim, attach copies of lien
documentation, and state annual interest rate and the amount past due
on the claim as of the date of the bankruptcy filing.
5. Amount of Claim Entitled to Priority Under 11 U.S.C. §507(a) .
If any portion of your claim falls in one or more of the listed
categories, check the appropriate box(es) and state the amount
entitled to priority. (See DEFINITIONS, below.) 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 proof 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 to this proof of claim form redacted copies documenting the existence
of the debt and of any lien securing the debt. You may also attach a summary.
You must also attach copies of documents that evidence perfection of any
security interest. You may also attach a summary. FRBP 3001(c) and (d).
If the claim is based on the delivery of health care goods or services, see
instruction 2. Do not send original documents, as attachments may be
destroyed after scanning.
Date and Signature:
The person filing 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. 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. Attach a complete copy of
any power of attorney. Criminal penalties apply for making a false statement
on a proof of claim.
__________DEFINITIONS__________ ______INFORMATION______
Debtor
A debtor is the person, corporation, or other entity that
has filed a bankruptcy case.
Creditor
A creditor is a person, corporation, or other entity owed a
debt by the debtor that arose on or 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 on a
debt owed by the debtor that arose 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 bankruptcy 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 property prior to other
creditors. The amount of the secured claim cannot
exceed the value of the property. Any amount owed to
the creditor 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 P riority 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 otherwise deleted, certain
information. A creditor should redact and use only the
last four digits of any social-security, individual’s tax-
identification, or financial-account number, all but the
initials of a minor’s name and only the year of any
person’s date of birth.
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.
Ackno wledgment 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 proof 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 bankruptcy 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.
