United States Bankruptcy Court District of Utah |
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Proof of Claim |
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Name of Debtor |
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Case Number |
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Note: This form should not be used to make a claim for an administrative expense arising after the commencement of the case. A |
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"request" of payment of an administrative expense may be filed pursuant to 11 U.S.C. §503. |
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Name of Creditor (the person or other entity to whom the |
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Check box if you are aware that anyone else has filed a |
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debtor owes money or property): |
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proof of claim relating to your claim. Attach copy of |
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statement giving particulars. |
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Check box if you have never received any notices from |
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the bankruptcy court in this case. |
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Name and Address Where Notices Should Be Sent |
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Check box if the address differs from the address on the |
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envelope sent to you by the bankruptcy court. |
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Account or other number by which creditor identifies debtor: |
Check here if this claim |
replaces or |
amends a previous claim, |
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THIS SPACE IS FOR |
1. |
Basis for Claim |
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COURT USE ONLY |
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Goods Sold |
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Retiree Benefits as defined in 11 U.S.C. §1114(a) |
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Services Performed |
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Wages, Salaried, and compensations (Fill out below) |
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Money loaned |
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Your Social Security Number _______________________ |
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Personal Injury/Wrongful Death |
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Unpaid compensation for services performed |
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Taxes |
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from ____________________ to ____________________ |
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2. Date Debt Was Incurred: |
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3. If court judgement, date obtained: |
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4. Total Amount of Claim at Time Case Filed: |
$ ____________________ |
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If all or part of your claim is secured or entitled to priority, also complete Item 5 or 6 below. |
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Check this box is claim includes interest or other charges in addition to the principal amount of the claim. Attach itemized statement of all interest or |
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5. |
Secured |
Claim |
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6. |
Unsecured Priority Claim |
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Check this box if your claim is secured by collateral (include a right of |
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Check this box if you have an unsecured priority claim. |
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setoff). |
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Amount entitled to priority $ ____________________ |
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Brief Description of Collateral: |
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Specify the priority of the claim: |
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Real Estate |
Motor Vehicle |
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Wages, Salaries, or commissions (up to $4,300)*, earned within 90 |
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Other: |
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days before filing of the bankruptcy petition or cessation of the debtor's |
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_____________________________________________________ |
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business, whichever is earlier. - 11 U.S.C. §507(a)(3) |
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Contributions to an employee benefit plan - 11 U.S.C. §507(a)(4) |
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Value of collateral: $______________________ |
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Up to $1,950* of deposits toward purchase, lease, or rental of property |
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or services for personal, family, or household use - 11 U.S.C. §507 (a)(6) |
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Amount of arrearage and other charges at time case filed included in |
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Taxes or penalties of governmental units - 11 U.S.C. § 507(a)(7) |
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secured claim above, if any: |
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Other - Specify applicable paragraph of 11 U.S.C. §§507(a)(_____) |
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7. |
Credits: The amount of all payments on this claim has been credited and deducted for the purpose of making this proof of |
THIS SPACE IS FOR |
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claim. |
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COURT USE ONLY |
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Supporting Documents: Attach copies of supporting documents , such as promissory notes, purchase orders, invoices, |
Please mail or file this form to: |
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itemized statements of running accounts, contracts, court judgments, mortgages, security interests, and evidence of |
U. S. BANKRUPTCY COURT |
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perfection of lien. DO NOT SEND ORIGINAL DOCUMENTS. If the documents are voluminous, attach a summary. |
350 SOUTH MAIN STREET |
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SALT LAKE CITY, UT 84101 |
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Date |
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Sign and print name and title, if any, of the creditor or other person authorized to file this |
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claim (attach copy of power of attorney, if any) |
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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 |
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