Form 410A Worksheet - Mortgage Proof of Claim Attachment
Worksheet only. Not the official form. Transfer to Official Form 410A (12/23). Required for claims secured by the debtor’s principal residence.
United States Bankruptcy Court
District of [District]
Debtor(s): [ ]
Case No.: [ ]
Creditor/Mortgagee: [ ]
Servicer (if different): [ ]
Court claim number (if known): [ ]
Loan number (last 4): [ ]
Property address: [ ]
Part 1: Mortgage and Case Information
- Escrow account? [ ] Yes [ ] No
- Interest calculation method: [ ] Fixed accrual [ ] Daily simple interest [ ] Other (describe): [ ]
- Fixed or adjustable rate? [ ] Fixed [ ] ARM
- Current interest rate: [ ]% | Next rate change (if ARM): [ ]
- Contractual principal and interest payment amount: $[ ] | Next P&I change date (if ARM): [ ]
Part 2: Total Debt Calculation (as of petition date)
- Principal balance: $[ ]
- Interest due (from [start date] to petition date): $[ ]
- Escrow deficiency: $[ ]
- Other amounts (describe): $[ ]
- Less total funds on hand (suspense/unapplied/positive escrow): ($[ ])
- Fees, costs, and expenses (itemize in Part 6): $[ ]
- Total debt: $[ ]
Part 3: Arrearage as of Petition Date
- Principal and interest due (from [start date] to [end date]): $[ ]
- Late charges: $[ ]
- Escrow deficiency for funds advanced: $[ ]
- Projected escrow shortage: $[ ]
- Fees/expenses outstanding (see Part 6): $[ ]
- Less funds on hand (suspense/unapplied/positive escrow): ($[ ])
- Total prepetition arrearage: $[ ]
Part 4: Monthly Mortgage Payment (as of petition date)
- Principal and interest: $[ ]
- Monthly escrow: $[ ]
- Private mortgage insurance (if any): $[ ]
- Other (describe): $[ ]
- Total monthly payment: $[ ]
Part 5: Loan Payment History (from first date of default through petition date)
List all transactions in date order. Each fee/charge shown here must be reflected in the balances.
| Date | Contractual payment due | Funds received | Amount incurred | Description | Applied to Principal | Applied to Interest | Applied to Escrow | Applied to Fees/Charges | Unapplied/Suspense after | Principal balance | Interest balance | Escrow balance | Fees/charges balance |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| [ ] | $[ ] | $[ ] | $[ ] | [ ] | $[ ] | $[ ] | $[ ] | $[ ] | $[ ] | $[ ] | $[ ] | $[ ] | $[ ] |
(Add rows as needed until the petition date. Ensure ending balances reconcile to Parts 2 and 3.)
Part 6: Itemized Fees, Expenses, and Charges Included in Claim/Arrearage
| Description | Incurred date | Amount | Included in arrearage? (Y/N) |
|---|---|---|---|
| [ ] | [ ] | $[ ] | [ ] |
Part 7: Statement of Escrow
- Attach escrow account statement prepared as of the petition date that meets Official Form 410A and applicable nonbankruptcy law.
- Escrow monthly component: $[ ]
- Next escrow analysis date: [ ]
Declaration
I declare under penalty of perjury that the information provided in this attachment is true and correct to the best of my knowledge, information, and reasonable belief.
Name: [ ]
Title/Relationship to creditor/servicer: [ ]
Address/Phone/Email: [ ]
Signature: __________________________ Date: __________
Privacy reminder (Rule 9037): Use only last 4 digits of account numbers; do not include full SSNs/TINs; use year-only for birth dates; redact minors’ names and other PII.