Free form210a.pdf - Virginia

Form 210A (10/06)

United States Bankruptcy Court
Eastern Virginia _______________ District Of _______________
In re ______________________________, Case No. ________________

TRANSFER OF CLAIM OTHER THAN FOR SECURITY
A CLAIM HAS BEEN FILED IN THIS CASE or deemed filed under 11 U.S.C. § 1111(a). Transferee hereby gives evidence and notice pursuant to Rule 3001(e)(2), Fed. R. Bankr. P., of the transfer, other than for security, of the claim referenced in this evidence and notice.

______________________________________

____________________________________

Name of Transferee Name and Address where notices to transferee should be sent:

Name of Transferor Court Claim # (if known): Amount of Claim: Date Claim Filed:

Phone: ______________________________ Last Four Digits of Acct #: ______________ Name and Address where transferee payments should be sent (if different from above):

Phone: Last Four Digits of Acct. #: __________

Phone: Last Four Digits of Acct #:

I declare under penalty of perjury that the information provided in this notice is true and correct to the best of my knowledge and belief. By:__________________________________ Transferee/Transferee's Agent Date:____________________________

Penalty for making a false statement: Fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §§ 152 & 3571.