Official Form 410 Proof of Claimpage1Official Form 410 Proof of Claim Read the instructions before filling out this form. This form is for making a claim for payment in a bankruptcy case. Do not use this form to make a request for payment of an administrative expense. Make such a request according to 11 U.S.C. 247 503. Filers must leave out or redact information that is entitled to privacy on this form or on any attached documents. 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. Do not send original documents; they may be destroyed after scanning. If the documents are not available, explain in an attachment. A person who files a fraudulent claim could be fined up to $500,000, imprisoned for up to 5 years, or both. 18 U.S.C. 247247 152, 157, and 3571. Fill in all the information about the claim as of the date the case was filed. That date is on the notice of bankruptcy (Form 309) that you received. Part 1: Identify the Claim 1.Who is the currentcreditor? Name of the current creditor (the person or entity to be paid for this claim) Other names the creditor used with the debtor 2.Has this claim beenacquired fromsomeone else?NoYes. From whom? 3.Where should noticesand payments to thecreditor be sent?Federal Rule ofBankruptcy Procedure(FRBP) 2002(g) Where should notices to the creditor be sent? Where should payments to the creditor be sent? (if different) Name Number Street City State ZIP Code Contact phone Contact email Name Number Street City State ZIPCode Contact phone Contact email Uniform claim identifier for electronic payments in chapter 13 (if you use one): 4.Does this claim amendone already filed?NoYes. Claim number on court claims registry (if known) Filed on MM / DD / YYYY 5.Do you know if anyoneelse has filed a proofof claim for this claim?NoYes. Who made the earlier filing? Debtor 1 Debtor 2 (Spouse, if filing) United States Bankruptcy Court for the: District of Case number Fill in this information to identify the case: American LegalNet, Inc. www.FormsWorkFlow.com Official Form 410 Proof of Claimpage2 Part 2: Give Information About the Claim as of the Date the Case Was Filed 6.Do you have any numberyou use to identify thedebtor?NoYes. Last 4 digits of the debtor222s account or any number you use to identify the debtor: 7.How much is the claim?$. Does this amount include interest or other charges? NoYes. Attach statement itemizing interest, fees, expenses, or othercharges required by Bankruptcy Rule 3001(c)(2)(A). 8.What is the basis of theclaim?Examples: Goods sold, money loaned, lease, services performed, personal injury or wrongful death, or credit card. Attach redacted copies of any documents supporting the claim required by Bankruptcy Rule 3001(c). Limit disclosing information that is entitled to privacy, such as health care information. 9.Is all or part of the claimsecured?NoYes. The claim is secured by a lien on property.Nature of property: Real estate. If the claim is secured by the debtor222s principal residence, file a Mortgage Proof of ClaimAttachment (Official Form 410-A) with this Proof of Claim. Motor vehicleOther. Describe: Basis for perfection: Attach redacted copies of documents, if any, that show evidence of perfection of a security interest (for example, a mortgage, lien, certificate of title, financing statement, or other document that shows the lien has been filed or recorded.) Value of property: $ Amount of the claim that is secured: $ Amount of the claim that is unsecured: $ (The sum of the secured and unsecured amounts should match the amount in line 7.) Amount necessary to cure any default as of the date of the petition: $ Annual Interest Rate (when case was filed) % FixedVariable 10.Is this claim based on alease?NoYes. Amount necessary to cure any default as of the date of the petition. $ 11.Is this claim subject to aright of setoff?NoYes. Identify the property: American LegalNet, Inc. www.FormsWorkFlow.com Official Form 410 Proof of Claimpage312.Is all or part of the claimentitled to priority under11 U.S.C. 247 507(a)?A claim may be partlypriority and partlynonpriority. For example,in some categories, thelaw limits the amountentitled to priority. Amount entitled to priority $ $ $ $ $ NoYes. Check one:Domestic support obligations (including alimony and child support) under11 U.S.C. 247 507(a)(1)(A) or (a)(1)(B).Up to $* of deposits toward purchase, lease, or rental of property or services forpersonal, family, or household use. 11 U.S.C. 247 507(a)(7).Wages, salaries, or commissions (up to $1,*) earned within 180 days before thebankruptcy petition is filed or the debtor222s business ends, whichever is earlier.11 U.S.C. 247 507(a)(4).Taxes or penalties owed to governmental units. 11 U.S.C. 247 507(a)(8).Contributions to an employee benefit plan. 11 U.S.C. 247 507(a)(5).Other. Specify subsection of 11 U.S.C. 247 507(a)() that applies. $ *Amounts are subject to adjustment on 4/01/ and every 3 years after that for cases begun on or after the date of adjustment. Part 3: Sign Below The person completing this proof of claim must sign and date it. FRBP 9011(b). If you file this claim electronically, FRBP 5005(a)(2) authorizes courts to establish local rules specifying what a signature is. A person who files a fraudulent claim could be fined up to $500,000, imprisoned for up to 5 years, or both. 18 U.S.C. 247247 152, 157, and 3571. Check the appropriate box: I am the creditor.I am the creditor222s attorney or authorized agent.I am the trustee, or the debtor, or their authorized agent. Bankruptcy Rule 3004.I am a guarantor, surety, endorser, or other codebtor. Bankruptcy Rule 3005.I understand that 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. I have examined the information in this Proof of Claim and have a reasonable belief that the information is true and correct. I declare under penalty of perjury that the foregoing is true and correct. Executed on date MM / DD / YYYYSignature Print the name of the person who is completing and signing this claim: NameFirst name Middle name Last name Title Company Identify the corporate servicer as the company if the authorized agent is a servicer. Address Number Street CityStateZIPCodeContact phone Email American LegalNet, Inc. www.FormsWorkFlow.com