Official Form Proof of Claim Corte Fed. Quiebra
Official Form Proof of Claim Corte Fed. Quiebra
Official Form Proof of Claim Corte Fed. Quiebra
Debtor 1 __________________________________________________________________
Debtor 2 ________________________________________________________________
(Spouse, if filing)
Read the instructions before filling out this form. This form is for making a claim for payment in a bankruptcy case. Do not use this form to
make a request for payment of an administrative expense. Make such a request according to 11 U.S.C. 503.
Filers must leave out or redact information that is entitled to privacy on this form or on any attached documents. Attach redacted copies of any
documents that support the claim, such as promissory notes, purchase orders, invoices, itemized statements of running accounts, contracts, judgments,
mortgages, and security agreements. Do not send original documents; they may be destroyed after scanning. If the documents are not available,
explain in an attachment.
A person who files a fraudulent claim could be fined up to $500,000, imprisoned for up to 5 years, or both. 18 U.S.C. 152, 157, and 3571.
Fill in all the information about the claim as of the date the case was filed. That date is on the notice of bankruptcy (Form 309) that you received.
3. Where should notices Where should notices to the creditor be sent? Where should payments to the creditor be sent? (if
and payments to the different)
creditor be sent?
_____________________________________________________ _____________________________________________________
Federal Rule of Name Name
Bankruptcy Procedure
(FRBP) 2002(g) ______________________________________________________ ______________________________________________________
Number Street Number Street
______________________________________________________ ______________________________________________________
City State ZIP Code City State ZIP Code
Uniform claim identifier for electronic payments in chapter 13 (if you use one):
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
7. How much is the claim? $_____________________________. Does this amount include interest or other charges?
No
Yes. Attach statement itemizing interest, fees, expenses, or other
charges required by Bankruptcy Rule 3001(c)(2)(A).
8. What is the basis of the Examples: Goods sold, money loaned, lease, services performed, personal injury or wrongful death, or credit card.
claim?
Attach redacted copies of any documents supporting the claim required by Bankruptcy Rule 3001(c).
Limit disclosing information that is entitled to privacy, such as health care information.
______________________________________________________________________________
Amount of the claim that is unsecured: $__________________ (The sum of the secured and unsecured
amounts should match the amount in line 7.)
Amount necessary to cure any default as of the date of the petition: $____________________
A claim may be partly Domestic support obligations (including alimony and child support) under
priority and partly 11 U.S.C. 507(a)(1)(A) or (a)(1)(B). $____________________
nonpriority. For example,
in some categories, the Up to $2,850* of deposits toward purchase, lease, or rental of property or services for
law limits the amount personal, family, or household use. 11 U.S.C. 507(a)(7). $____________________
entitled to priority.
Wages, salaries, or commissions (up to $12,850*) earned within 180 days before the
bankruptcy petition is filed or the debtors business ends, whichever is earlier. $____________________
11 U.S.C. 507(a)(4).
Taxes or penalties owed to governmental units. 11 U.S.C. 507(a)(8). $____________________
* Amounts are subject to adjustment on 4/01/19 and every 3 years after that for cases begun on or after the date of adjustment.
8________________________________________________________________________
Signature
Print the name of the person who is completing and signing this claim:
Name _______________________________________________________________________________________________
First name Middle name Last name
Title _______________________________________________________________________________________________
Company _______________________________________________________________________________________________
Identify the corporate servicer as the company if the authorized agent is a servicer.
Address _______________________________________________________________________________________________
Number Street
_______________________________________________________________________________________________
City State ZIP Code