B 10 (Attachment A) (12/11) Mortgage Proof of Claim Attachment If you file a claim secured by a security interest in the debtor’s principal residence, you must use this form as an attachment to your proof of claim. See Bankruptcy Rule 3001(c)(2). Name of debtor: ___________________________________ Case number: ___________________ Name of creditor: ___________________________________ Last four digits of any number you use to identify the debtor’s account: ____ ____ ____ ____ Part 1: Statement of Principal and Interest Due as of the Petition Date Itemize the principal and interest due on the claim as of the petition date (included in the Amount of Claim listed in Item 1 on your Proof of Claim form). (1) $ ________ Copy total here ► (2) + $ ________ (3) $ ________ 1. Principal due 2. Interest due Interest rate From To mm/dd/yyyy mm/dd/yyyy Amount _________% __/__/____ __/__/____ $ _______ _________% __/__/____ __/__/____ $ _______ _________% __/__/____ __/__/____ + $ _______ Total interest due as of the petition date $ _______ 3. Total principal and interest due Part 2: Statement of Prepetition Fees, Expenses, and Charges Itemize the fees, expenses, and charges due on the claim as of the petition date (included in the Amount of Claim listed in Item 1 on the Proof of Claim form). Description 1. Late charges Dates incurred Amount 12. Insurance advances (non-escrow) ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ 13. Escrow shortage or deficiency (Do not include amounts that are part of any installment payment listed in Part 3.) ___________________________ 2. Non-sufficient funds (NSF) fees 3. Attorney’s fees 4. Filing fees and court costs 5. Advertisement costs 6. Sheriff/auctioneer fees 7. Title costs 8. Recording fees 9. Appraisal/broker’s price opinion fees 10. Property inspection fees 11. Tax advances (non-escrow) 14. Property preservation expenses. Specify:______________ 15. Other. Specify:_____________________________________ 16. Other. Specify:_____________________________________ 17. Other. Specify:_____________________________________ 18. Total prepetition fees, expenses, and charges. Add all of the amounts listed above. $ ________ (2) $ ________ (3) $ ________ (4) $ ________ (5) $ ________ (6) $ ________ (7) $ ________ (8) $ ________ (9) $ ________ (10) $ ________ (11) $ ________ (12) $ ________ (13) $ ________ (14) $ ________ (15) $ ________ (16) $ ________ (17) + $ ________ (18) ___________________________ ___________________________ ___________________________ ___________________________ (1) $ ________ American LegalNet, Inc. www.FormsWorkFlow.com B 10 (Attachment A) (12/11) Page 2 Part 3. Statement of Amount Necessary to Cure Default as of the Petition Date Does the installment payment amount include an escrow deposit?  No  Yes. Attach to the Proof of Claim form an escrow account statement prepared as of the petition date in a form consistent with applicable nonbankruptcy law. 1. Installment payments due Date last payment received by creditor Number of installment payments due 2. Amount of installment payments due _____installments @ _____installments @ _____installments @ Total installment payments due as of the petition date 3. Calculation of cure amount __/__/____ (1) ________ $ ________ $ ________ + $ ________ $ ________ Add total prepetition fees, expenses, and charges Copy total here ► (2) Copy total from Part 2 here ► $ ________ + $ _________ Subtract total of unapplied funds (funds received but not credited to account) - $ _________ Subtract amounts for which debtor is entitled to a refund - $ _________ Total amount necessary to cure default as of the petition date (3) $ _________ Copy total onto Item 4 of Proof of Claim form American LegalNet, Inc. www.FormsWorkFlow.com