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MOW 3094.1.5 (10/08)

IN THE UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF MISSOURI

PROOF OF CLAIM ­ ADDENDUM FOR REAL ESTATE CLAIMS Debtor: Case No. Creditor

1. PRE-PETITION ARREARAGE: a. Mortgage Payments ­ # _______ @ $____________ b. Late Fees - # _______@ $_______________ c. Other Fees i. Inspection Fee - $_______________ ii. Escrow Shortage - $_________________ iii. Attorney's Fees - $__________________ d. TOTAL ARREARAGE: $_______________

2, ESTIMATED PAYOFF: a. b. c. d. e. f. g. Unpaid Principal Balance - $_________________ Interest from Last Paid Installment - $__________________ Escrow Shortage - $_______________ Late Fees - $______________ Property Inspection Fee ­ $_____________ Other TOTAL ESTIMATED PAYOFF: $_______________

2. CURRENT MONTHLY PAYMENT: a. b. c. d. e. Principal and Interest payment - $__________________ Escrow Payment - $______________ TOTAL CURRENT MONTHLY PAYMENT - $_____________ Effective Date of Current Monthly Payment: CURRENT CONTRACT RATE OF INTEREST: ___________%