LBR Form 3001-1 If the mortgage is to be paid inside the plan, attach this form to the mortgage proof of claim. UNITED STATES BANKRUPTCY COURT FOR THE SOUTHERN DISTRICT OF OHIO WESTERN/EASTERN DIVISION Case No: In re: Chapter 13 Debtor(s) Judge PROOF OF CLAIM MORTGAGE ARREARAGE BREAKDOWN ATTACHMENT Current monthly payment amount is: $_____________ Effective ___________ (date) the new monthly payment is: $_____________ This mortgage IS/IS NOT subject to impound/escrow – i.e., taxes and insurance. Address of property: __________________________________________________________________________ Principal balance as of the petition filing date: $_____________ Monthly payment: $_____________ Principal and interest Taxes Insurance PMI $_____________ $_____________ $_____________ $_____________ Detail of arrearage: ___ (# of payments) from _____ (date) to _____ (date) @ $_____________ = $______________ ___ (# of late charges) from ______ (date) to _____ (date) @ $____________ = $____________ American LegalNet, Inc. www.FormsWorkFlow.com Costs and out-of-pocket expenses: Foreclosure title work Filing fee Skip trace Document acquisition costs Service process server Other (specify): ________________________________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ Other charges: Escrow shortage Hazard insurance – ________________ (dates) Taxes – ________________ (dates) Appraisal BPO charges Property inspection Other (specify): ________________________________ TOTAL ARREARAGE: $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ American LegalNet, Inc. www.FormsWorkFlow.com