Free Proof of Claim Form / Exhibit(s) Summary and Certificate of Service combined Benton (* - Illinois

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State: Illinois
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B10 (Official Form 10)(12/08)

United States Bankruptcy Court Southern District of Illinois
Name of Debtor:

Case Number:

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 owes money or property): Check this box to indicate that this claim amends a previously filed Name and address where notices should be sent: claim. Court Claim Number:_____________ (If known) Telephone number: Name and address where payment should be sent(if different from above): Filed on: _________________ 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. $________________________ 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. FOR COURT USE ONLY US Bankruptcy Court 301 W. Main St. Benton, IL 62812-1362

Telephone number: 1. Amount of Claim as of Date Case Filed:

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. A copy of the itemized statement of all interest or additional charges must be provided to debtor's attorney and trustee. 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 Unsecured: $_______________

Amount of Secured Claim: $_______________

6. Credits: The amount of all payments on this claim has been credited for the purpose of making this proof of claim. 7. Supporting Documents: Exhibits (e.g., leases, promissory notes, mortgages, titles) may by filed electronically subject to the restrictions listed in General Order 08-4. A Summary of Exhibits may be filed electronically in lieu of filing the actual exhibits pursuant to General Order 08-4. If a Summary of Exhibits is filed, the proof of claim and Summary of Exhibits shall be filed together electronically as a single document. A copy of the claim and exhibits, (documentation of your lien), in paper format that complies with the redaction policy as described on the back of this form, must still be provided to debtor's attorney and trustee. Exhibits must be tendered to the Court at least five days prior to the Court hearing to which they pertain. Any Exhibit that is filed with the Court shall comply with the privacy protection requirements set forth in Bankruptcy Rule 9037.


Signature: The person filing this claim must sign it. Sign and print name and title, if any, of the creditor or other person authorized to file this claim and state address and telephone number if different from the notice address above. 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.

Revised 06/23/04


SUMMARY OF EXHIBIT(S) The following exhibit(s) pertaining to the___________________________________________________ filed by______________________________________________________________________________ on _________________________________ is(are) available upon request. Movant will bring exhibit(s) to any scheduled Court hearing on this matter.


CERTIFICATE OF SERVICE The undersigned hereby certifies that a true and accurate copy of all exhibit(s) listed above were deposited in the United States mail, first class, postage prepaid, on _______________________________ addressed to the following: