Court, Name of Debtor, and Case Number:
Fill in the federal judicial district in which the bankruptcy case was filed (for
example, Central District of California), the debtor's full name, and the case
number. If the creditor received a notice of the case from the bankruptcy court,
all of this information is at the top of the notice.
Creditor's Name and Address:
Fill in the name of the person or entity asserting a claim and the name and
address of the person who should receive notices issued during the bankruptcy
case. A separate space is provided for the payment address if it differs from the
notice address. The creditor has a continuing obligation to keep the court
informed of its current address. See Federal Rule of Bankruptcy Procedure
1. Amount of Claim as of Date Case Filed:
State the total amount owed to the creditor on the date of the bankruptcy filing.
Follow the instructions concerning whether to complete items 4 and 5. Check
the box if interest or other charges are included in the claim.
2. Basis for Claim:
State the type of debt or how it was incurred. Examples include goods sold,
money loaned, services performed, personal injury/wrongful death, car loan,
mortgage note, and credit card. If the claim is based on delivering health care
goods or services, limit the disclosure of the goods or services so as to avoid
embarrassment or the disclosure of confidential health care information. You
may be required to provide additional disclosure if an interested party objects to
3. Last Four Digits of Any Number by Which Creditor Identifies Debtor:
State only the last four digits of the debtor's account or other number used by the
creditor to identify the debtor.
3a. Debtor May Have Scheduled Account As:
Report a change in the creditor's name, a transferred claim, or any other
information that clarifies a difference between this proof of claim and the claim
as scheduled by the debtor.
3b. Uniform Claim Identifier:
If you use a uniform claim identifier, you may report it here. A uniform claim
identifier is an optional 24-character identifier that certain large creditors use to
facilitate electronic payment in chapter 13 cases.
4. Secured Claim:
Check whether the claim is fully or partially secured. Skip this section if the claim
is entirely unsecured. (See Definitions.) If the claim is secured, check the box for
the nature and value of property that secures the claim, attach copies of lien
documentation, and state, as of the date of the bankruptcy filing, the annual interest
rate (and whether it is fixed or variable), and the amount past due on the claim.
5. Amount of Claim Entitled to Priority Under 11 U.S.C. §507(a).
If any portion of the claim falls into any category shown, check the appropriate
box(es) and state the amount entitled to priority. (See Definitions.) A claim may
be partly priority and partly non-priority. For example, in some of the categories,
the law limits the amount entitled to priority.
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.
Attach redacted copies of any documents that show the debt exists and a lien
secures the debt. You must also attach copies of documents that evidence perfection
of any security interest. You may also attach a summary in addition to the
documents themselves. FRBP 3001(c) and (d). If the claim is based on delivering
health care goods or services, limit disclosing confidential health care information.
Do not send original documents, as attachments may be destroyed after scanning.
8. Date and Signature:
The individual completing this proof of claim must sign and date it. FRBP 9011.
If the claim is filed electronically, FRBP 5005(a)(2) authorizes courts to establish
local rules specifying what constitutes a signature. If you sign this form, you
declare under penalty of perjury that the information provided is true and correct to
the best of your knowledge, information, and reasonable belief. Your signature is
also a certification that the claim meets the requirements of FRBP 9011(b).
Whether the claim is filed electronically or in person, if your name is on the
signature line, you are responsible for the declaration. Print the name and title, if
any, of the creditor or other person authorized to file this claim. State the filer's
address and telephone number if it differs from the address given on the top of the
form for purposes of receiving notices. If the claim is filed by an authorized agent,
attach a complete copy of any power of attorney, and provide both the name of the
individual filing the claim and the name of the agent. If the authorized agent is a
servicer, identify the corporate servicer as the company. Criminal penalties apply
for making a false statement on a proof of claim.
A debtor is the person, corporation, or other entity
that has filed a bankruptcy case.
A creditor is a person, corporation, or other entity to
whom debtor owes a debt that was incurred before
the date of the bankruptcy filing. See 11 U.S.C.
A claim is the creditor's right to receive payment for
a debt owed by the debtor on the date of the
bankruptcy filing. See 11 U.S.C §101(5). A claim
may be secured or unsecured.
Proof of Claim
A proof of claim is a form used by the creditor to
indicate the amount of the debt owed by the debtor
on the date of the bankruptcy filing. The creditor
must file the form with the clerk of the same
bankruptcy court in which the bankruptcy case was filed.
Secured Claim Under 11 U.S.C. §506(a)
A secured claim is one backed by a lien on property
of the debtor. The claim is secured so long as the
creditor has the right to be paid from the property
prior to other creditors. The amount of the secured
claim cannot exceed the value of the property. Any
amount owed to the creditor in excess of the value of
the property is an unsecured claim. Examples of
liens on property include a mortgage on real estate or
a security interest in a car. A lien may be voluntarily
granted by a debtor or may be obtained through a
court proceeding. In some states, a court judgment is
a lien. A claim also may be secured if the creditor owes the
debtor money (has a right to setoff).
An unsecured claim is one that does not meet the
requirements of a secured claim. A claim may be
partly unsecured if the amount of the claim exceeds
the value of the property on which the creditor has a
Claim Entitled to Priority Under 11 U.S.C.
Priority claims are certain categories of unsecured
claims that are paid from the available money or
property in a bankruptcy case before other unsecured
A document has been redacted when the person filing
it has masked, edited out, or otherwise deleted,
certain information. A creditor must show only the
last four digits of any social-security, individual's
tax-identification, or financial-account number, only
the initials of a minor's name, and only the year of
any person's date of birth. If the claim is based on the
delivery of health care goods or services, limit the
disclosure of the goods or services so as to avoid
embarrassment or the disclosure of confidential
health care information.
Evidence of Perfection
Evidence of perfection may include a mortgage, lien,
certificate of title, financing statement, or other
document showing that the lien has been filed or
Acknowledgment of Filing of Claim
To receive acknowledgment of your filing, you may
either enclose a stamped self-addressed envelope anda
a copy of this proof of claim or you may access the
court's PACER system
(www.pacer.psc.uscourts.gov) for a small fee to view
your filed proof of claim.
Offers to Purchase a Claim
Certain entities are in the business of purchasing
claims for an amount less than the face value of the
claims. One or more of these entities may contact the
creditor and offer to purchase the claim. Some of the
written communications from these entities may
easily be confused with official court documentation
or communications from the debtor. These entities
do not represent the bankruptcy court or the debtor.
The creditor has no obligation to sell its claim.
However, if the creditor decides to sell its claim, any
transfer of such claim is subject to FRBP 3001(e),
any applicable provisions of the Bankruptcy Code
(11 U.S.C. § 101 et seq.), and any applicable orders
of the bankruptcy court.