THIS SPACE IS FOR COURT USE ONLY
UNITED STATES BANKRUPTCY COURT
District of Oregon
Name of Debtor:
PROOF OF CLAIM
Name of Creditor (the person or other entity to whom the debtor owes money or property) (NOTE: STRIKE any preprinted text that is incorrect AND type or print correct information):
Check this box to indicate that this claim amends a previously filed claim. Court Claim#_______(If known) Filed on: ___________
Name and address where notices should be sent:
Check this box if you are aware that anyone else has filed a proof of claim relating to your claim. Attach copy of statement giving particulars. Check this box if you are the debtor or trustee in this case.
Telephone Number: Name and address where payment should be sent (if different from above):
Telephone Number: 1. Amount of Claim as of Date Case Filed: $_______________________ 5. Amount of Claim Entitled to Priority under 11 U.S.C. §507(a). If any portion of your claim falls in one of the following categories, check the box and state the amount. Specify the priority of the claim: Domestic support obligations under 11 U.S.C. §507(a)(1)(A) or (a)(1)(B). 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). 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). Taxes or penalties owed to governmental units - 11 U.S.C. §507(a)(8). Other - Specify applicable paragraph of 11 U.S.C. §507(a)(___). Amount entitled to priority: $____________________ *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.
If all or part of your claim is secured, complete item 4 below; however, if all of your claim is unsecured, do not complete item 4. If all or part of your claim is entitled to priority, complete item 5. Check this box if claim includes interest or other charges in addition to the principal amount of claim. Attach itemized statement of interest or charges. 2. Basis for Claim: (See instruction #2 on reverse side.) 3. Last four digits of any number by which creditor identifies debtor: ____________________ 3a. Debtor may have scheduled account as: (See instruction #3a on reverse side.) 4. Secured Claim (See instruction #4 on reverse side.) Check the appropriate box if your claim is secured by a lien on property or a right of setoff and provide the requested information. Nature of property or right of setoff: Describe: Real Estate Motor Vehicle Other
Value of Property: $____________________ Annual Interest Rate _______% Amount of arrearage and other charges as of time case filed included in secured claim, if any: $____________________ Basis for perfection:
Amount of Secured Claim: $____________________ Amount Unsecured: $____________________ 6. Credits: The amount of all payments on this claim has been credited for the purpose of making this proof of claim. 7. Documents: Attach 8 1/2 x 11 INCH redacted copies of any documents that support the claim, such as promissory notes, purchase orders, invoices, itemized statements or running accounts, contracts, judgments, mortgages, and security agreements. You may also attach a summary. Attach redacted copies of documents providing evidence of perfection of a security interest. You may also attach a summary. (See instruction 7 and definition of "redacted" on reverse side.) DO NOT SEND ORIGINAL DOCUMENTS. ATTACHED DOCUMENTS MAY BE DESTROYED AFTER SCANNING. If the documents are not available, please explain:
SIGN AND PRINT the name title, if any, of the person authorized to file ¦ this claim and state address ANDtelephone number creditor or other the notice address above. and if different from ¦ Attach copy of power of attorney, if any. ¦ ¦ ¦ NOTE: DO NOT FILE CLAIM IF SAME ONE ALREADY FILED IN THIS CASE!!
MAIL CLAIM TO:
Clerk, U.S. Bankruptcy Court (If the 5-digit portion of the Case No. begins with a "3" or "4", mail to 1001 SW 5th Ave. #700, Portland OR 97204; OR if it begins with a "6" or "7", mail to 405 E 8th Ave #2600, Eugene OR 97401.)
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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B10 (12/08) - Cont.
INSTRUCTIONS FOR PROOF OF CLAIM FORM
The instructions and definitions below are general explanations of the law. In certain circumstances, such as bankruptcy cases not filed voluntarily by the debtor, there may be exceptions to these general rules.
Items to be Completed in Proof of Claim Form
Name of Debtor and Case Number: Fill in the bankruptcy debtor's name, and the bankruptcy case number. If the creditor received a notice of the case from the bankruptcy court, all of this information is located at the top of the notice. unsecured. (See DEFINITIONS, below.) State the type and the value of property that secures the claim, attach copies of lien documentation and state annual interest rate and the amount past due on the claim as of the date of the bankruptcy filing.
Creditor's Name and Address: Fill in the name of the person or entity asserting a claim and the name and 5. Amount of Claim Entitled to Priority Under 11 U.S.C. §507(a): If any portion of your claim falls in one or more of the listed categories, check address of the person who should receive notices issued during the bankruptcy the appropriate box(es) and state the amount entitled to priority. (See case. A separate space is provided for the payment address if it differs from the DEFINITIONS, below.) A claim may be partly priority and partly non-priority. notice address. The creditor has a continuing obligation to keep the court For example, in some of the categories, the law limits the amount entitled to informed of its current address. See Federal Rule of Bankruptcy Procedure priority. (FRBP) 2002(g). 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 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. You may be required to provide additional disclosure if the trustee or another party in interest files an objection to your claim. 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: Use this space to 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. 4. Secured Claim: Check the appropriate box and provide the requested information if the claim is fully or partially secured. Skip this section if the claim is entirely __________DEFINITIONS__________ voluntarily granted by a debtor or may be obtained Debtor A debtor is the person, corporation, or other entity through a court proceeding. In some states, a court judgment is a lien. A claim also may be secured if the that has filed a bankruptcy case. creditor owes the debtor money (has a right to setoff). Creditor A creditor is a person, corporation, or other entity Unsecured Claim owed a debt by the debtor that arose on or before An unsecured claim is one that does not meet the the date of the bankruptcy filing. See 11 U.S.C. requirements of a secured claim. A claim may be partly unsecured if the amount of the claim exceeds §101(10). the value of the property on which the creditor has a lien. Claim A claim is the creditor's right to receive payment on a debt owed by the debtor that arose on the date of Claim Entitled to Priority Under 11 U.S.C. §507(a) the bankruptcy filing. See 11 U.S.C. §101(5). A Priority claims are certain categories of unsecured claims that are paid from the available money or claim may be secured or unsecured. property in a bankruptcy case before other unsecured claims. 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 Redacted on the date of the bankruptcy filing. The creditor A document has been redacted when the person filing must file the form with the clerk of the same it has masked, edited out, or otherwise deleted, bankruptcy court in which the bankruptcy case was certain information. A creditor should redact and use only the last four digits of any social-security, filed. individual's taxpayer-identification, or financial-account number, all but the initials of a Secured Claim Under 11 U.S.C. §506(a) A secured claim is one backed by a lien on property minor's name and only the year of any person's date of the debtor. The claim is secured so long as the of birth. creditor has the right to be paid from the property prior to other creditors. The amount of the secured Evidence of Perfection claim cannot exceed the value of the property. Any Evidence of perfection may include a mortgage, lien, amount owed to the creditor in excess of the value certificate of title, financing statement, or other of the property is an unsecured claim. Examples document showing that the lien has been filed or of liens on property include a mortgage on real recorded. estate or a security interest in a car. A lien may be ______INFORMATION______ Acknowledgment of Filing of Claim To receive acknowledgment of your filing, you may either enclose a stamped self-addressed envelope and a copy of this proof of claim if it is filed on paper, or you may access the court's PACER system at https://ecf.orb.uscourts.gov for a small fee to view your filed proof of claim. Visit the PACER Service Center at http://www.pacer.psc.uscourts.gov to register if you do not have a PACER account. 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. 6. Credits: 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. 7. Documents: Attach to this proof of claim form redacted copies documenting the existence of the debt and of any lien securing the debt. You may also attach a summary. You must also attach copies of documents that evidence perfection of any security interest. You may also attach a summary. FRBP 3001(c) and (d). If the claim is based on the delivery of health care goods or services, see instruction 2. Do not send original documents, as attachments may be destroyed after scanning. Date and Signature: The person filing 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. 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. Attach a complete copy of any power of attorney. Criminal penalties apply for making a false statement on a proof of claim.
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