B 10 (Official Form 10) (12/11) UNITED STATES BANKRUPTCY COURT __________ DISTRICT OF __________ Name of Debtor: PROOF OF CLAIM 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 to11 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 previously filed claim. Name and address where notices should be sent: Court Claim Number:______________ (If known) Telephone number: email: Filed on:_____________________ ❐ 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 particulars. Name and address where payment should be sent (if different from above): 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 by which creditor identifies debtor: ___ ___ ___ ___ 3a. Debtor may have scheduled account as: 3b. Uniform Claim Identifier (optional): _____________________________ (See instruction #3a) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ (See instruction #3b) Amount of arrearage and other charges, as of the time case was filed, included in secured claim, if any: 4. Secured Claim (See instruction #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 Describe: ❐Motor Vehicle ❐Other $__________________ Basis for perfection: _______________________________________ Value of Property: $________________ Amount of Secured Claim: $__________________ Annual Interest Rate_______% ❐Fixed or ❐Variable (when case was filed) Amount 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). ❐ 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). ❐ Wages, salaries, or commissions (up to $11,725*) 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). ❐ Taxes or penalties owed to governmental units – 11U.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. 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) American LegalNet, Inc. www.FormsWorkFlow.com B 10 (Official Form 10) (12/11) 2 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, mortgages, and security agreements. 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. (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. (Attach copy of power of attorney, if any.) ❐ 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 claim is true and correct to the best of my knowledge, information, and reasonable belief. Print Name: _________________________________________________ Title: _________________________________________________ Company: _________________________________________________ Address and telephone number (if different from notice address above): (Signature) (Date) _________________________________________________ _________________________________________________ _________________________________________________ Telephone number: email: 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. 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: 4. Secured Claim: Fill in the federal judicial district in which the bankruptcy case was filed (for Check whether the claim is fully or partially secured. Skip this section if the claim example, Central District of California), the debtor’s full name, and the case is entirely unsecured. (See Definitions.) If the claim is secured, check the box for number. If the creditor received a notice of the case from the bankruptcy court, the nature and value of property that secures the claim, attach copies of lien all of this information is at the top of the notice. 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. Creditor’s Name and Address: Fill in the name of the person or entity asserting a claim and the name and 5. Amount of Claim Entitled to Priority Under 11 U.S.C. §507(a). address of the person who should receive notices issued during the bankruptcy If any portion of the claim falls into any category shown, check the appropriate case. A separate space is provided for the payment address if it differs from the box(es) and state the amount entitled to priority. (See Definitions.) A claim may notice address. The creditor has a continuing obligation to keep the court be partly priority and partly non-priority. For example, in some of the categories, informed of its current address. See Federal Rule of Bankruptcy Procedure the law limits the amount entitled to priority. (FRBP) 2002(g). 6. Credits: An authorized signature on this proof of claim serves as an acknowledgment that 1. Amount of Claim as of Date Case Filed: State the total amount owed to the creditor on the date of the bankruptcy filing. when calculating the amount of the claim, the creditor gave the debtor credit for Follow the instructions concerning whether to complete items 4 and 5. Check any payments received toward the debt. the box if interest or other charges are included in the claim. 7. Documents: Attach redacted copies of any documents that show the debt exists and a lien 2. Basis for Claim: secures the debt. You must also attach copies of documents that evidence perfection State the type of debt or how it was incurred. Examples include goods sold, of any security interest. You may also attach a summary in addition to the money loaned, services performed, personal injury/wrongful death, car loan, documents themselves. FRBP 3001(c) and (d). If the claim is based on delivering mortgage note, and credit card. If the claim is based on delivering health care health care goods or services, limit disclosing confidential health care information. goods or services, limit the disclosure of the goods or services so as to avoid Do not send original documents, as attachments may be destroyed after scanning. embarrassment or the disclosure of confidential health care information. You may be required to provide additional disclosure if an interested party objects to the claim. 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 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 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 creditor to identify the debtor. 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). 3a. Debtor May Have Scheduled Account As: Whether the claim is filed electronically or in person, if your name is on the Report a change in the creditor’s name, a transferred claim, or any other signature line, you are responsible for the declaration. Print the name and title, if information that clarifies a difference between this proof of claim and the claim any, of the creditor or other person authorized to file this claim. State the filer’s as scheduled by the debtor. 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, 3b. Uniform Claim Identifier: attach a complete copy of any power of attorney, and provide both the name of the If you use a uniform claim identifier, you may report it here. A uniform claim individual filing the claim and the name of the agent. If the authorized agent is a identifier is an optional 24-character identifier that certain large creditors use to servicer, identify the corporate servicer as the company. Criminal penalties apply facilitate electronic payment in chapter 13 cases. for making a false statement on a proof of claim. American LegalNet, Inc. www.FormsWorkFlow.com B 10 (Official Form 10) (12/11) 3 __________DEFINITIONS__________ 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 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 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 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 otherwise 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. ______INFORMATION______ 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 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. 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. American LegalNet, Inc. www.FormsWorkFlow.com