Proof of Claim Template (Official Form 410) - Free Editor
Proof of Claim Template (Official Form 410)
United States Bankruptcy Court
District of [District]
In re: [Debtor Name(s)]
Case No.: [Number]
Part 1: Identify the Claim
- Who is the current creditor? [Name]
- Has this claim been acquired from someone else? ☐ Yes ☐ No – If yes, from whom?
- Where should notices be sent? [Address, phone, email]
- Does this claim amend a previously filed proof of claim? ☐ Yes ☐ No – Claim number: [ ]
- Does this claim secure a right to setoff? ☐ Yes ☐ No – Explain.
Part 2: Claim Amount
- Amount of claim as of petition date: $[Amount].
- Interest, fees, other charges included? ☐ Yes (provide itemized statement) ☐ No.
Part 3: Basis of Claim
- Basis for claim (e.g., goods sold, money loaned, services, credit card, judgment).
Part 4: Secured Claim
- Is claim secured by property? ☐ Yes ☐ No. If yes, describe collateral and attach proof of lien.
- Value of collateral: $[Value].
- Amount of secured claim: $[Amount].
- Amount unsecured: $[Amount].
- Nature of lien: ☐ Real estate mortgage ☐ Statutory lien ☐ Security interest ☐ Judgment lien ☐ Other.
- Is collateral property insured? ☐ Yes (attach certificate) ☐ No.
Part 5: Priority Claim
- Is claim entitled to priority under 11 U.S.C. § 507(a)? ☐ No ☐ Yes – specify type:
- ☐ Domestic support obligations (§ 507(a)(1))
- ☐ Wages, salaries (§ 507(a)(4))
- ☐ Taxes (§ 507(a)(8))
- ☐ Other priority: [Describe] - Amount of priority claim: $[Amount].
Part 6: Supporting Documentation
- Attach redacted copies of any documents supporting the claim (invoices, contracts, judgments, security agreements). Explain if documents not available.
Part 7: Sign and Date
- I am the creditor or authorized agent.
- I have examined the information in this Proof of Claim and it is true and correct to the best of my knowledge.
Signature: ____ Date: __
Name: [Printed Name]
Title: [Title]
Company: [Creditor Name]
Address: [Address]
Phone: [Phone]
Email: [Email]
Penalty for presenting fraudulent claim: Fine up to $500,000, imprisonment up to 5 years, or both (18 U.S.C. §§ 152, 157, 3571).
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