B10 (Official Form 10)(12/08)
United States Bankruptcy Court Southern District of Illinois
PROOF OF CLAIM
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.
Court Claim Number: If known
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.
2. Basis for Claim: 3. Last four digits of any number by which creditor identifies debtor: 3a. Debtor may have scheduled account as 4. Secured Claim
Nature of property or right of setoff: Describe: 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 Unsecured: $_______________
Amount of Secured Claim 6. Credits: 7. Supporting Documents:
Amount entitled to priority: ______________ f rn *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. FOR COURT USE ONLY
Penalty for presenting fraudulent claim: