Official Form 410 Proof of Claim

The Georgia Bankruptcy Proof of Claim Form is used for filing for bankruptcy in the State of Georgia. The mentioned form has to be submitted to the District Office in the State of Georgia. You can download the form from the following link.

Extracted Text for Proper Search

B 10 (Official Form 10) (12/12)	 	 
UNITED	 STATES	 BANKRUPTCY	 COURT	 	District of 	Georgia	 	 	PROOF OF CLAIM	 	 	 	 	 	 	 	 	 	 	 	 	 	Name of Debtor:	 	 	 	Case Number:	  	 	 	 	
 	 	 	 	NOTE:  	Do not use this form to make a claim for an administrative expense that	 arises	 after the bankruptcy filing. You	  	 	 	may file a request for payment of an administrative expense according to 11 U.S.C. § 503.	  	 	 	 	 	 	 	 	 	 	Name of Creditor (the person or other entity to whom the debtor owes money or property):	  	 	 	 	 	
 	 	 	 	 	 	 	COURT USE ONLY	 	 	Name and address where notices should be sent:	 	 	 	 	 	❐ Check this box if this claim amends a	 	 	 	 	 	 	 	 	previously filed claim.	 	 	
 	 	 	 	 	 	Court Claim Number:	______________	 	 	
Telephone number:	 	email:	 	 	 	 	 	(If known	) 	 	 	 	 	 	Filed on:_____________________	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Name and address where payment should be sent (if different from above):	  	 	 	❐ Check this box if you are aware that	 	 	 	 	 	 	 	 	anyone else has filed a proof of claim	 	 	 	 	 	 	 	 	relating to this claim.  Attach copy of	 	 	 	 	 	 	 	 	statement giving particulars.	 	 	
Telephone number:	 	email:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
1.  Amount of Claim as of Date Case Filed:	 	$_______________________________	 	 	 	 	 	
If all or part of the claim is secured, complete item 4.	  	 	 	 	 	 	 	
If all or part of the claim is entitled to priority, complete item 5.	 	 	 	 	 	 	 	
❐Check this box if the claim includes interest or other charges in addition to the principal amount of the claim.  Attach a st	atement that itemizes interest or charges.	 	 	
2.  Basis for Claim:  _________________________________________________________________	 	 	 	 	 	(See instruction #2)	 	 	 	 	 	 	 	 	 	 	 	 	 	
3.   Last four digits of any number	 	 3a.  Debtor may have scheduled account as:	 	3b. Uniform Claim Identifier (optional):	 	 	by which creditor identifies debtor:	  _____________________________	 	__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __	  	
___  ___  ___  ___	 	 	 	 (See instruction #3a)	 	 	(See instruction #3b)	 	 	 	 	
4.  Secured Claim 	(See instruction #4)	 	 	 	 	Amount of arrearage and other charges, as of the time case was filed,	 	 	 	 	 	included in secured claim, if any:	 	 	 	Check the appropriate box if the claim is secured by a lien on property or a right of	 	 	 	
$__________________	 	 	setoff, attach required redacted documents, and provide the requested information.	 	 	 	 	
Nature of property or right of setoff:  	❐Real Estate	 ❐Motor Vehicle	 ❐Other	 	Basis for perfection: _______________________________________	 	 	Describe:	 	 	 	 	 	 	 	 	 	
Value of Property: $________________	  	 	 	Amount of Secured Claim:	 	$__________________	 	 	 	 	 	 	 	 	 	 	
An nual Interest Rate_ __ __ __ % 	❐Fix ed	 or   	❐Variable	 	 	Amount Unsecured:	 	$__________________	 	 	 	 	 	 	 	 	(when case was filed)	 	 	 	 	 	 	 	 	 	 	 	
5.  Amount of Claim Entitled to Priority under 11 U.S.C. § 507 (a).  If any part of the claim falls into one of the following	 categories, check the box specifying	 	 	the priority and state the amount.	 	 	 	 	 	 	 	 	 	
❐ Domestic support obligations under 11	 	❐ Wages, salaries, or commissions (up to $11,725*)	 	❐ Contributions to an	 	 	 	U.S.C. § 507 (a)(1)(A) or (a)(1)(B).	 	earned within 180 days before the case was filed or the	 	employee benefit plan 	–  	 	 	debtor’s business ceased, whichever is earlier 	– 	11 U.S.C. §	 507 (a)(5).	 	
Amount entitled to priority:	 	 	 	11 U.S.C. § 507 (a)(4).	 	 	 	 	 	 	
❐ Up to $2,600* of deposits toward	 	❐ Taxes or penalties owed to governmental units 	– 	❐ Other 	– Specify	 	$______________________	 	 	 	 	purchase, lease, or rental of property or	 	11 U.S.C. § 507 (a)(8).	 	 	 	applicable paragraph of	  	 	services for personal, family, or household	 	 	 	 	11 U.S.C. § 507 (a)(__).	  	 	use 	– 11 U.S.C. § 507 (a)(7).	 	 	 	 	 	 	 	 	 	
*Amounts are subject to adjustment on 4/1/13 and every 3 years thereafter with respect to cases commenced on or after the dat	e of adjustment.	 	 	 	 	
6.  Credits.  	The amount of all payments on this claim has been credited for the purpose of making this proof of claim. (See instruction #6	)

B 10 (Official Form 10) (12/12) 2 	7. Documents: 	Attached are	 redacted 	copies of any docum	ents that support the claim, such as promissory notes, purchase orders, 	invoices, itemized statements of	 running accounts, contracts, judgments, mortgages, security agreements, or, in the case of a claim based on an open	-end or revolving 	consumer credit ag	reement, a statement providing the information required by FRBP 3001(c)(3)(A). If the claim is secured, box 4 has been comple	ted, and 	redacted	 	copies of documents providing evidence of perfection of a security interest are attached. If the claim is secured	 by the debtor's principal residence, the Mortgage Proof 	of Claim Attachment is being filed with this claim. 	(See instruction #7, and the definition of “	redacted	”.) 	
 
DO NOT SEND ORIGINAL DOCUMENTS.  ATTACHED DOCUMENTS MAY BE DESTROYED AFTER SCANNING.	 	 If the documents are not available, please explain:	 	 
8.  Signature:  	(See instruction #8)	 	 	 	
Check the appropriate box.	 	 	 	
❐ I am the creditor.	 	❐ I am the creditor’s authorized agent.	 	❐ I am the trustee, or the debtor,	 	❐ I am a g uar antor, s urety, in dors er, or  other  cod eb tor.	 	 	 	or their authorized agent.	 	(See Bankruptcy Rule 3005.)	 	
 	 	(See Bankruptcy Rule 3004.)	 	 	 I declare under penalty of perjury that the information provided in this claim is true and correct to the best of my knowledg	e, information, and reasonable belief.	 	 Print Name:  _________________________________________________	 	Title:	 	_____________________	____________________________	 	Company:     _________________________________________________	 	Address and telephone number (if different from notice address above):	 	(Signature)	 	(Date)	 	 	_________________________________________________	 	 	 	 	 	_________________________________________________	 	 	 	 	_________________________________________________	 	 	 	 	Telephone number:	 	email:	 	 	 	 	Penalty for presenting fraudulent claim:  	Fine of up to $500,000 or imprisonment for up to 5 years, or both.	 18 U .S.C. 	§ § 15 2 and 3 571 .	  	 	INSTRUCTIONS FOR PROOF OF CLAIM FORM	 	The instructions and definitions below are general explanations of the law. In certain circumstances, such as bankruptcy case	s not filed voluntarily by the debtor, 	exceptions to these general 	rules may apply.	 	 	Items to be completed in Proof of Claim form	 	 Court, Name of Debtor, and Case Number:	 	Fill in the federal judicial district in which the bankruptcy case was filed (for example, Central District of 	Georgia	), the de	btor’s full name, and the case 	number. If the creditor received a notice of the case from the bankruptcy court, all of this information is at the top of the notice.	 	 Creditor’s Name and Address:	 	Fill in the name of the person or entity asserting a claim an	d the name and 	address of the person who should receive notices issued during the bankruptcy case. A separate space is provided for the payment address if it differs from the notice address. The creditor has a continuing obligation to keep the court inform	ed of its current address. See Federal Rule of Bankruptcy Procedure 	(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 ty	pe 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 delivering health care goods or services, limit the disclos	ure 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 an interested party objects to the claim.	 	 3.  Last Four Digits of Any Number by Wh	ich 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	: 	 Report a change in the creditor’s name, a transferred claim, o	r any other 	information that clarifies a difference between this proof of claim and the claim as scheduled by the debtor.	 	 3b. Uniform Claim Identifier:	 	If you use a uniform claim identifier, you may report it here. A uniform claim identifier is an optional 24	-character identifier that certain large creditors use 	to facilitate electronic payment in chapter 13 cases.	 	 4.   Secured Claim:	 	Check whether the c	laim is fully or partially secured. Skip this section if the	 	
 claim is entirely unsecured. (See Definitions.) If the claim is secured, check the box for the nature and value of property that secures the claim, attach copies of lien documentation, and stat	e, as of the date of the bankruptcy filing, the annual interest rate 	(and whether it is fixed or variable), and the amount past due on the claim.	 	 5.   Amount of Claim Entitled to Priority Under 11 U.S.C. § 507 (a).	 	 If any portion of the claim falls in	to any category shown, check the appropriate 	box(es) and state the amount entitled to priority. (See Definitions	.) A claim may 	be partly priority and partly non	-priority. For example, in some of the categories, 	the law limits the amount e	ntitled to priority.	 	 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 redacted copies of any documents that show the debt exists and a lien secures the debt. You must also attach copies of documents that evidence perfection of any security interest and documents required by FRBP 3001(c) for claims based on an open	-end	 or revolving consumer credit agreement or secured by 	a security interest in the debtor’s principal residence. You may also attach a summary in addition to the documents themselves. FRBP 3001(c) and (d). If the claim is based on delivering health care good	s or services, limit disclosing 	confidential health care information. Do not send original documents, as attachments may be destroyed after scanning.	 	 8.   Date and Signature:	 	 The  individual  completing 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.  If  you  sign  this  form,  you declare under  penalty of perjury that  the information provided  is true and  correct to the 	best  of  your  knowledge,  information,  and  reasonable  belief.  Your  signature  is 	also  a  certification  that  the  claim  meets  the  requirements  of  FRBP  9011(b). Whether  the  claim  is  filed  electronically  or  in  person,  if  your  name  is  on  the signature  line,  you  are	 responsible  for  the  declaration.  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  re	ceiving  notices.  If  the  claim  is  filed  by  an  authorized  agent, 	provide both the  name  of  the individual  filing the  claim and the  name  of the agent. If  the authorized agent  is a  servicer, identify the corporate  servicer as  the  company. Criminal penalties app	ly for making a false statement on a proof of claim.

B 10 (Official Form 10) (12/12)	 	3 	 __________DEFINITIONS__________	 	 ______INFORMATION______	 	 Debtor	 	A debtor is the person, corporation, or other entity 
that has filed a bankruptcy case.	 	 Creditor	 	A creditor is a person, corporation, or other entity to whom debtor owes a debt that was incurred before the date of the bankruptcy filing. See 11 U.S.C. §101 	(10).	 	 Claim	 	A claim is the creditor’s right to receive payment for a debt owed by the debtor on the date of the bankruptcy filing. See 11 U.S.C. §101 (5). A claim may be secured or unsecured.	 	 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 on the date of the bankruptcy filing. The creditor must file the form with the clerk of the same bankruptcy court in which the bankruptcy case was filed.	 	 Secured Claim Under 11 U.S.C. § 506 (a)	 	 A secured claim is one backed by a lien on property of the debtor. The claim is secured so long as the creditor has the right to be paid from the property prior to other creditors. The amount of the secured claim c	annot exceed the value of the property. Any 	amount owed to the creditor in excess of the value of the property is an unsecured claim. Examples of liens on property include a mortgage on real estate or a security interest in a car. A lien may be voluntarily	 	granted by a debtor or may be obtained through a court proceeding. In some states, a court judgment is a lien.	 	
 A claim also may be secured if the creditor owes 
the debtor money (has a right to setoff).	 	 Unsecured Claim	 	An unsecured claim is one that doe	s not meet the 	requirements of a secured claim. A claim may be partly unsecured if the amount of the claim exceeds the value of the property on which the creditor has a lien.	 	 Claim Entitled to Priority Under 11 U.S.C. § 507	 	(a) Priorit	y claims are certain categories of unsecured 	claims that are paid from the available money or property in a bankruptcy case before other unsecured claims.	 	 Redacted	 	A document has been redacted when the person filing it has masked, edited out, or otherwise	 deleted, 	certain information. A creditor must show only the last four digits of any social	-security, individual’s tax 	-identification, or financial	-account number, only the 	initials of a minor’s name, and only the year of any person’s date of birth. If th	e 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.	 	 Evidence of Perfection	 	 Evidence of perfection may inc	lude a mortgage, lien, 	certificate of title, financing statement, or other document showing that the lien has been filed or recorded.	 	
 Acknowledgment of Filing of Claim	 	To receive acknowledgment of your filing, you may either enclose a sta	mped self 	-addressed envelope 	and a copy of this proof of claim or you may access the court’s PACER system (www.pacer.psc.uscourts.gov	) for a small fee to 	view	 your filed proof of claim.	 	 Offers to Purchase a Claim	 	Certain entities are in the business of p	urchasing 	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 subjec	t 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.	 	
 
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