B 10 (Supplement 1) (12/11) UNITED STATES BANKRUPTCY COURT __________ District of __________ In re ___________________________________, Case No. _______________________ Debtor Chapter 13 Notice of Mortgage Payment Change If you file a claim secured by a security interest in the debtor's principal residence provided for under the debtor's plan pursuant to § 1322(b)(5), you must use this form to give notice of any changes in the installment payment amount. File this form as a supplement to your proof of claim at least 21 days before the new payment amount is due. See Bankruptcy Rule 3002.1. Name of creditor: _______________________________________ Court claim no. (if known): _____________________ Last four digits of any number you use to identify the debtor’s account: Date of payment change: Must be at least 21 days after date of this notice ____/____/_____ New total payment: ____ ____ ____ ____ $ ___________ Principal, interest, and escrow, if any Part 1: Escrow Account Payment Adjustment Will there be a change in the debtor’s escrow account payment?   No Yes. Attach a copy of the escrow account statement prepared in a form consistent with applicable nonbankruptcy law. Describe the basis for the change. If a statement is not attached, explain why: _____________________________________________________ Current escrow payment: $ _______________ New escrow payment: $ _______________ Part 2: Mortgage Payment Adjustment Will the debtor’s principal and interest payment change based on an adjustment to the interest rate in the debtor's variable-rate note?   No Yes. Attach a copy of the rate change notice prepared in a form consistent with applicable nonbankruptcy law. If a notice is not attached, explain why: _______________________________________________________________ Current interest rate: _______________% Current principal and interest payment: $ _______________ New interest rate: _______________% New principal and interest payment: $ _______________ Part 3: Other Payment Change Will there be a change in the debtor’s mortgage payment for a reason not listed above?   No Yes. Attach a copy of any documents describing the basis for the change, such as a repayment plan or loan modification agreement. (Court approval may be required before the payment change can take effect.) Reason for change: ___________________________________________________________________________________ Current mortgage payment: $ _______________ New mortgage payment: $ _______________ American LegalNet, Inc. www.FormsWorkFlow.com B 10 (Supplement 1) (12/11) Page 2 Part 4: Sign Here The person completing this Notice must sign it. Sign and print your name and your title, if any, and state your address and telephone number if different from the notice address listed on the proof of claim to which this Supplement applies. Check the appropriate box. ❐ I am the creditor. ❐ I am the creditor’s authorized agent. (Attach copy of power of attorney, if any.) I declare under penalty of perjury that the information provided in this Notice is true and correct to the best of my knowledge, information, and reasonable belief.  _____________________________________________________________ Date ____/_____/________ Title ___________________________ Signature Print: _________________________________________________________ First Name Middle Name Last Name Company _________________________________________________________ Address _________________________________________________________ Number Street ___________________________________________________ City Contact phone (______) _____– _________ State ZIP Code Email ________________________ American LegalNet, Inc. www.FormsWorkFlow.com