Free b10f.pdf - Virginia

ANY ATTACHMENTS MUST BE 8-1/2 X 11"
B 10 (Official Form 10) (04/07)

UNITED STATES BANKRUPTCY COURT _____________ DISTRICT OF ___________________________________
Name of Debtor Case Number

PROOF OF CLAIM

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 Check box if you are aware that anyone else has filed a proof of owes money or property): claim relating to your claim. Attach copy of statement giving particulars. Name and address where notices should be sent: Check box if you have never received any notices from the bankruptcy court in this case. Check box if the address differs from the address on the envelope sent to you by the court. Check here if this claim replaces amends
THIS SPACE IS FOR COURT USE ONLY

Telephone number: Last four digits of account or other number by which creditor identifies debtor: 1. Basis for Claim Goods sold Services performed Money loaned

a previously filed claim, dated:____________________ Wages, salaries, and compensation (fill out below) Last four digits of your SS #:____ Unpaid compensation for services performed From ______________ to (date)

Personal injury/wrongful death Taxes Retiree benefits as defined in 11 U.S.C. § 1114(a) Other___________________________

___________
(date)

2. Date debt was incurred:

3. If court judgment, date obtained:

4. Classification of Claim. Check the appropriate box or boxes that best describe your claim and state the amount of the claim at the time the case was filed. See reverse side for important explanations. Secured Claim Unsecured Nonpriority Claim $________________________ Check this box if your claim is secured by collateral (including a right of setoff). Check this box if: a) there is no collateral or lien securing your claim, or b) Brief Description of Collateral: your claim exceeds the value of the property securing it, or c) none or only part Real Estate Other_____________________________ of your claim is entitled to priority. Motor Vehicle Unsecured Priority Claim Check this box if you have an unsecured claim, all or part of which is entitled to priority. Amount entitled to priority $____________________________ Specify the priority of the claim: Domestic support obligations under 11 U.S.C. § 507(a)(1)(A) or (a)(1)(B). Taxes or penalties owed to governmental units - 11 U.S.C. § 507(a)(8). Wages, salaries, or commissions (up to $10,950),* earned within 180 days before filing of the bankruptcy petition or cessation of the debtor's business, whichever is earlier - 11 U.S.C. § 507(a)(4). Contributions to an employee benefit plan - 11 U.S.C. § 507(a)(5). 5. Total Amount of Claim at Time Case Filed: Other ­ Specify applicable paragraph of 11 U.S.C. § 507(a)(___). *Amounts are subject to adjustment on 4/1/10 and every 3 years thereafter with respect to cases commenced on or after the date of adjustment. Up to $2,425* of deposits toward purchase, lease, or rental of property or services for personal, family, or household use - 11 U.S.C. § 507(a)(7). Value of Collateral: $_____________________

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

$________________ _______________ _______________ ______________ (unsecured) (secured) (priority) (total) 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. THIS SPACE IS FOR COURT 6. Credits: The amount of all payments on this claim has been credited and deducted for the purpose of making this proof of claim.
USE ONLY

7. 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. If the documents are voluminous, attach a summary. 8. 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 up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §§ 152 and 3571.

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