FORM B10 (Official Form 10) (4/01)

UNITED STATES BANKRUPTCY COURT __________________ DISTRICT OF_________________

 

PROOF OF CLAIM

 

Name of Debtor

 

 

Case Number

 

NOTE: This form should not be used to make a claim for an administrative expense arising after the commencement of the case.  A request for payment of an administrative expense may be filed pursuant to 11 U.S.C. § 503.

 

Name of Creditor (The person or other entity to whom the debtor owes money or property).

 

 

 

ٱ Check box if you are aware that

    anyone else has filed a proof of

    claim relating to your claim. 

    Attach copy of statement giving

    particulars.

ٱ  Check box if you have never

     received any notices from the

     bankruptcy court in this case.

ٱ  Check box if the address

     differs from the address on the

     envelope sent to you by the

     court.

 

Name and address where notices should be sent:

 

 

 

 

Telephone number:

Account or other number by which creditor identifies debtor:

Check here

                      ٱ  replaces

 

 

if this claim                     previously filed claim, dated: _____________

 

 

                         ٱ  amends

 

1.  Basis for Claim                                                                         ٱ  Retiree benefits as defined in 11 U.S.C. § 1114(a)

 

ٱ Goods sold                                                                                         ٱ Wages, salaries, and compensation (fill out below)

 

ٱ Services performed                                                                                 Your SS#: ___________   _____________   ____________

 

ٱ Money loaned                                                                                         Unpaid compensation for services performed

 

ٱ Personal injury/wrongful                                                                         from _______________ to ___________________

ٱ Taxes                                                                                                          (date)                         (date)

 

ٱ Other  _______________________________

 

2. Date debt was incurred:

 

3. If court judgment, date obtained:

 

4. Total Amount of Claim at Time Case Filed:                 $ ________________________________

 

     If all or part of your claim is secured or entitled to priority, also complete Item 5 or 6 below.

 

ٱ Check this box if claim includes interest or other charges in addition to the principal amount of the

     claim. Attach itemized statement of all interest or additional charges.

 

5. Secured Claim.

6. Unsecured Priority Claim.

 

ٱ Check this box if your claim is secured by collateral (including a

ٱ  Check this box if you have an unsecured priority claim

 

     right of setoff).

     Amount entitled to priority $_________________

 

    Brief Description of Collateral:

    Specify the priority of the claim:

 

    ٱ Real Estate         ٱ Motor Vehicle

         ٱ Other _____________

 

 

      Value of Collateral:    $ _________________

 

 

 

 

 

 

 

 

     Amount of arrearage and other charges at time case filed included in secured claim, if any: $_________________

    ٱ Wages, salaries, or commissions (up to $4,650),* earned within 90

         days before filing of the bankruptcy petition or cessation of the

         debtor’s business, whichever is earlier - 11 U.S.C. §507(a)(3).

     ٱ Contributions to an employee benefit plan - 11 U.S.C. 

         §507(a)(4)

     ٱ  Up to $2,100* of deposits toward purchase, lease, or rental of property or services for  

         persona, family, or household use - 11 U.S.C. §507(a)(6)

     ٱ  Alimony, maintenance, or support owed to a spouse, former spouse, or child - 11

         U.S.C. §507(a)(7).

     ٱ  Taxes or penalties owed to governmental units - 11 U.S.C. §507(a)(8).

     ٱ  Other - Specify applicable paragraph of 11 U.S.C. §507(a)(____).

*Amounts are subject to adjustment on 4/1/04 and every 3 years thereafter with respect to cases commenced on or after the date of adjustment.

 

 

 

 

7.   Credits: The amount of all payments on this claim has been credited and deducted for the purpose of making this proof of claim.

THIS SPACE IS FOR COURT USE ONLY

 

8.   Supporting Documents:  Attach copies of supporting documents, such as promissory notes, purchase orders, invoices, itemized 

      statements of running accounts, contracts, court judgments, mortgages, security agreements, and evidence of perfection of lien.  DO 

      NOT SEND ORIGINAL DOCUMENTS.  If the documents are not available, explain.   f the documents are voluminous, attach a

      summary.

9.   Date-Stamped Copy: To receive an acknowledgment of the filing of your claim, enclose a stamped, self-addressed envelope and  

      copy of this proof of claim 

 

 

Date

Sign and print the name and title, if any, of the creditor or other person authorized to file

 

 

 

this claim (attach copy of power of attorney, if any):

 

 

Penalty for presenting fraudulent claim: Fine of a to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §§ 152 and 3571.