Massachusetts Bankruptcy Proof of Claim Form

The Massachusetts Bankruptcy Proof of Claim is a form that has to be submitted to the District Office in order to be able to file for bankruptcy. This form can be used in the State of Massachusetts.

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FORM B10	 (Official Form 10)(4/99) 	
UNITED STATES BANKRUPTCY COURT 
DISTRICT OF MASSACHUSETTS PROOF OF CLAIM 
Chapter 11 	
DEBTOR: 
 	
CASE NO. 	
 	
  	
NOTE:  This form should not be used to make a claim for an administrative expense arising after the commencement of the 
case other than for claims associated with benefits arising under the Retirement and Benfit Plans pursuant to Orders entered by 
the Bankruptcy Court.	
 	
 	
Name of Creditor (The person or other entity to whom the debtor owes money 
or property)	 
 
 	
 	
†  Check 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 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.	
 	
If address differs from above, please complete the following: 
Creditor Name:  
 
Address: 
 
City/St/Zip: 	Telephone # 
 
 	
 
 
 
 
 
 
 
 
 
 
 
 	
  
 
This Space is for Court Use  
Only 	
 Account or other number by which creditor identifies debtor: 
 Check here if 
this claim † replaces 
† amends  
a previously filed claim, dated ________ 
1.   Basis for Claim 
† Goods sold 
† Services performed 
† Money loaned 
†  Personal injury/wrongful death 
† Taxes 
Other ________________________________ 
 †  Retiree benefits as defined in 11 U.S.C. §1114(a) 
†  Wages, salaries, and compensation (fill out below) 
  Your SS #: ____________________________ 
  Unpaid compensation for services performed 
  from ____________ to __________________ 
 (date)  (date) 
2. Date debt was incurred: 3. If court judgment, date obtained: 
 
4. Total Amount of Claim at Time Case Filed: $ ____________ If all or part of your claim is secured or entitled to priority, also complete Item 5 or 6 below. 
†  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. 
5. Secured Claim. 
† 	Check this box if your claim is secured by collateral (including a 
right of setoff). 
Brief Description of Collateral: 
† Real Estate 	† Motor Vehicle 	
† Other__________________ 
 
Value of Collateral:    $___________________________ 
 
 
 
 
  Amount of arrearage and other charges at time case filed	
 included 
in secured claim, if any: $__________________ 6. Unsecured Priority Claim. 
†  Check this box if you have an unsecured priority claim. 
  Amount entitled to priority $ _______	
 
  Specify the priority of the claim: 
† Wages, salaries, or commissions (up to $4,650), earned within 90 days 
before filing of the bankruptcy petition or cessation of the debtor's 
business, whichever is earlier - 11 U.S.C. § 507(a)(3). 
† Contributions to an employee benefit plan – 11 U.S.C. §507(a)(4). 
† Up to $ 2,100 of deposits toward purchase, lease, or rental of property or 
services for personal, family, or household use - 11 U.S.C. § 507(a)(6). 
† Alimony, maintenance, or support owed to a spouse, former spouse, or 
child - 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)(__) or 11 
U.S.C. § 503 (administrative expense claims). 	
 	7. Credits:  The amount of all payments on this claim has been credited and deducted for the purpose of making this proof of 
claim. 
8. 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. 
9. 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.	
 	
 
This Space is for Court Use Only	 	
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.

FORM Bl0 (Official Form l0)(4/99)
Instructions for Proof of Claim Form 
     The instructions and definitions below are general explanations of the law.  In particular types of cases or circumstances, such as bankruptcy cases that are not filed 
voluntarily by a debtor, there may be exceptions to these general rules. 
     Any creditor holding a scheduled claim which is not listed as disputed, contingent, or unliquidated as to amount may, but is not required to, file a proof of claim in 
these cases.  Creditors whose claims are not scheduled or whose claims are listed as disputed, contingent, or unliquidated as to amount and who desire to participate in the 
cases or share in any distribution must file a proof of claim.  A creditor who desires to rely on the schedule of creditors has the responsibility for determining that the 
claim is listed accurately.  The schedules are available at www.trumbullbankruptcy.com	
.   
     If you wish to file a claim against Divine, inc. Debtor, please fill out the proof of claim(s) and mail the form(s) with your original signature along with any supporting 
documentation to us at the address below.  We cannot accept faxed copies.  Please contact the Divine, inc. hotline supported by Trumbull Services, LLC at (860) 687-
3974 if you have any questions.  You can also obtain general information regarding this case via our website at www.trumbullbankruptcy.com	
.  SEND 
COMPLETED PROOF OF CLAIM FORM TO: 
 
By U.S. Mail:	
                                                                                                     By Hand Delivery or Overnight Courier	: 
divine, inc.                                                                                                           divine, inc. 
c/o Trumbull Services, LLC                                                                               c/o Trumbull Services, LLC 
P. O. Box 1098                                                                                                    4 Griffin Road North 
Windsor, CT 06095                                                                                            Windsor, CT 06095	
 	 	DEFINITIONS 	 
Debtor 
 
The person, corporation, or other entity that has filed 
a bankruptcy case is called the debtor. 
 
Creditor 
 
A creditor is any person, corporation, or other entity 
to whom the debtor owed a debt on the date that the 
bankruptcy case was filed. 
 
Proof of Claim 
 
A form telling the bankruptcy court how much the 
debtor owed a creditor at the time the bankruptcy 
case was filed (the amount of the creditor's claim).  
This form must be filed with the clerk of the 
bankruptcy court where the bankruptcy case was 
filed. 
  
Secured Claim 
 
A claim is a secured claim to the extent that the 
creditor has a lien on property of the debtor 
(collateral) that gives the creditor the right to be 
paid from that property before creditors who do 
not have liens on the property. 
 
Examples of liens are a mortgage on real estate 
and a security interest in a car, truck, boat, 
television set, or other item of property.  A lien 
may have been obtained through a court 
proceeding before the bankruptcy case began; in 
some states a court judgment is a lien.  In 
addition, to the extent a creditor also owes 
money to the debtor (has a right of setoff), the 
creditor’s claim may be a secured claim. (See 
also Unsecured Claim) 
 
  
Unsecured Claim 
 
If a claim is not a secured claim it is an unsecured 
claim.  A claim may be partly secured and partly 
unsecured if the property on which a creditor has a 
lien is not worth enough to pay the creditor in full. 
 
Unsecured Priority Claim 
 
Certain types of unsecured claims are given priority, 
so they are to be paid in bankruptcy cases before most 
other unsecured claims (if there is sufficient money or 
property available to pay these claims).  The most 
common types of priority claims are listed on the 
proof of claim form.  Unsecured claims that are not 
specifically given priority status by the bankruptcy 
laws are classified as Unsecured Nonpriority Claims. 
 	
Items to be completed in Proof of Claim form (if not already filled in) 	Court, Name of Debtor, and Case Number: 
Fill in the name of the federal judicial district where the bankruptcy case 
was filed (for example, Central District of California), the name of the 
debtor in the bankruptcy case, and the bankruptcy case number.  If you 
received a notice of the case from the court, all of this information is near 
the top of the notice. 
 
Information about Creditor: 
Complete the section giving the name, address, and telephone number of 
the creditor to whom the debtor owes money or property, and the debtor's 
account number, if any.  If anyone else has already filed a proof of claim 
relating to this debt, if you never received notices from the bankruptcy 
court about this case, if your address differs from that to which the court 
sent notice, or if this proof of claim replaces or changes a proof of claim 
that was already filed, check the appropriate box on the form. 
 
1. Basis for Claim: 
Check the type of debt for which the proof of claim is being filed.  If the 
type of debt is not listed, check "Other" and briefly describe the type of 
debt.  If you were an employee of the debtor, fill in your social security 
number and the dates of work for which you were not paid. 
 
2. Date Debt Incurred: 
Fill in the date when the debt first was owed by the debtor. 
 
3. Court Judgments: 
If you have a court judgment for this debt, state the date the court entered 
the judgment. 
 4. Total Amount of Claim at Time Case Filed: 
Fill in the total amount of the entire claim.  If interest or other charges in 
addition to the principal amount of the claim are included, check the 
appropriate place on the form and attach an itemization of the interest and 
charges. 
 
5. Secured Claim: 
Check the appropriate place if the claim is a secured claim.  You must 
state the type and value of property that is collateral for the claim, attach 
copies of the documentation of your lien, and state the amount past due on 
the claim as of the date the bankruptcy case was filed.  A claim may be 
partly secured and partly unsecured. (See DEFINITIONS, above). 
 
6. Unsecured Priority Claim: 
Check the appropriate place if you have an unsecured priority claim, and 
state the amount entitled to priority. (See DEFINITIONS, above).  A 
claim may be partly priority and partly nonpriority if, for example, the 
claim is for more than the amount given priority by the law.  Check the 
appropriate place to specify the type of priority claim. 
 
7. Credits: 
By signing this proof of claim, you are stating under oath that in 
calculating the amount of your claim you have given the debtor credit for 
all payments received from the debtor. 
 
8. Supporting Documents: 
You must attach to this proof of claim form copies of documents that 
show the debtor owes the debt claimed or, if the documents are too 
lengthy, a summary of those documents.  If documents are not available, 
you must attach an explanation of why they are not available.