Mortgage Proof of Claim Attachment Part 1: Mortgage and Case Information Case number: Debtor 1: Debtor 2: Last 4 digits to identify: Creditor: Servicer: Fixed accrual/daily simple interest/other: ____________________ ____________________ ____________________ ___ ___ ___ ___ ____________________ ____________________ ____________________ Part 2: Total Debt Calculation Principal balance: Interest due: Fees, costs due: Escrow deficiency for funds advanced: Total debt: __________ __________ __________ __________ __________ Part 3: Arrearage as of Date of the Petition Principal & interest due: Prepetition fees due: Escrow deficiency for funds advanced: Projected escrow shortage: Less funds on hand: Total prepetition arrearage: ____________ ____________ ____________ ____________ ­ ____________ ____________ (12/15) 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 separate instructions. Part 4: Monthly Mortgage Payment Principal & interest: Monthly escrow: Private mortgage insurance: Total monthly payment: _____________ _____________ _____________ _____________ Less total funds on hand: ­ __________ Part 5 : Loan Payment History from First Date of Default Account Activity A. B. C. D. E. F. G. How Funds Were Applied/Amount Incurred H. I. J. Amount to escrow K. L. Balance After Amount Received or Incurred M. N. O. P. Q. Date Contractual Funds Amount Description Contractual Prin, int & Amount Amount esc past due to payment received incurred due date to balance amount principal interest Amount Unapplied Principal Accrued Escrow Fees / Unapplied balance interest balance Charges funds to fees or funds charges balance balance balance Official Form 410A Mortgage Proof of Claim Attachment American LegalNet, Inc. www.FormsWorkFlow.com page 1 of __ Mortgage Proof of Claim Attachment: Additional Page Case number: Debtor 1: Part 5 : Loan Payment History from First Date of Default Account Activity A. B. C. D. E. F. G. How Funds Were Applied/Amount Incurred H. I. J. Amount to escrow K. L. (12/15) Balance After Amount Received or Incurred M. N. O. P. Q. Date Contractual Funds Amount Description Contractual Prin, int & Amount Amount payment received incurred due date esc past due to to balance amount principal interest Amount Unapplied Principal Accrued Escrow Fees / Unapplied to fees or funds balance interest balance Charges funds charges balance balance balance Official Form 410A Mortgage Proof of Claim Attachment American LegalNet, Inc. www.FormsWorkFlow.com page __ of __