Form 410 Worksheet - Proof of Claim (with 410A/S1/S2 references)

Worksheet only. Not the official form. Transfer to Official Form 410 or e-filing portal. Use Official Form 410A for a mortgage on the debtor’s principal residence and 410S1/410S2 for postpetition mortgage notices.

United States Bankruptcy Court
District of [District]

Debtor: ☐
Case No.: ☐
Creditor: ☐
Other names the debtor used with this creditor: ☐
Last 4 digits of any number the debtor used to identify the account: ☐

Part 1: Identify the Claim

• Who is the current creditor? ☐
• Has this claim been acquired from someone else? ☐ No ☐ Yes → From whom? ☐
• Where should notices be sent? Name/Address/Phone/Email: [___]
• Where should payments be sent (if different)? Name/Address/Phone/Email: [___]
• Does this claim amend a previously filed claim? ☐ No ☐ Yes → Claim No. [___] filed on ☐

Part 2: Claim Amount as of Petition Date

• Total claim amount (U.S. dollars): $[___]
• Does this amount include interest or other charges? ☐ Yes ☐ No
• If yes, briefly describe basis for interest/fees/costs: [___]

Part 3: Basis of the Claim

• Basis (e.g., goods sold, money loaned, services performed, lease, judgment, taxes): [___]
• Date debt was incurred: [___]
• Is claim subject to a right of setoff? ☐ Yes ☐ No
• Is claim based on a lease? ☐ Yes ☐ No
• Is claim subject to recoupment or netting agreements (e.g., swap, repo, forward)? ☐ Yes ☐ No
• Supporting documents attached (check all): ☐ Promissory note ☐ Statement/invoice ☐ Purchase order ☐ Judgment ☐ Security agreement ☐ Assignment ☐ Other: ☐

Part 4: Secured Claim Details (if any)

• Is all or part of the claim secured? ☐ Yes ☐ No
• If Yes, describe collateral: [___] (e.g., real estate, vehicle, equipment, inventory, accounts)
• Basis of perfection (e.g., UCC filing, mortgage/recording info, possession, control): [___]
• Value of collateral: $[___]
• Amount of claim that is secured: $[___]
• Amount of claim that is unsecured (if any): $[___]
• Annual interest rate: ☐% ☐ Fixed ☐ Variable
• Arrearage or other amount owed as of petition date: $[___]
• Are you claiming any setoff rights? ☐ Yes ☐ No

Mortgage on the Debtor’s Principal Residence

• If collateral is the debtor’s principal residence, attach Official Form 410A Mortgage Proof of Claim Attachment.
• Postpetition notices: use 410S1 (Notice of Mortgage Payment Change) and 410S2 (Notice of Postpetition Fees, Expenses, and Charges) as required.

Part 5: Priority Claim (11 U.S.C. §507)

• Is any part of the claim entitled to priority? ☐ No ☐ Yes
• Amount entitled to priority: $[___]
• Check the applicable paragraph of §507(a):
• ☐ Domestic support obligations (a)(1)
• ☐ Wages, salaries, commissions (a)(4)
• ☐ Contributions to employee benefit plans (a)(5)
• ☐ Certain farmer/fisherman claims (a)(6)
• ☐ Deposits for purchase/lease/rental (a)(7)
• ☐ Taxes or penalties owed to governmental units (a)(8)
• ☐ Commitments to a federal depository institutions regulatory agency (a)(9)
• ☐ Personal injury or death claims from DUI/Intoxication (a)(10)
• ☐ Other priority (specify): [___]

Part 6: Sign and Date

I am the creditor or the creditor’s authorized agent. I declare under penalty of perjury that the information provided in this claim is true and correct to the best of my knowledge, information, and reasonable belief.

• Name: [___]
• Title/Relationship to creditor: [___]
• Company (if any): [___]
• Address/Phone/Email: [___]
• Signature: ________________________________ Date: __________

Filing and Redaction Reminders

• File electronically if permitted; otherwise mail to the bankruptcy clerk at the address on the notice.
• Do not include full SSNs, full birth dates, full account numbers, or names of minors; redact per Bankruptcy Rule 9037.
• Attach redacted copies of supporting documents. If voluminous, provide a summary and make originals available upon request.
• If you have secured collateral, include evidence of perfection. If mortgage on principal residence, attach Form 410A.
• If this is an amended claim, clearly mark it and identify the prior claim number/date.