Bankruptcy Forms - Proof of Claim Form

UNITED STATES BANKRUPTCY COURT

DISTRICT OF

Name of Debtor:

Case Number:

NOTE:   Do not use this form to make a claim for an administrative expense that arises after the bankruptcy filing. You

may file a request for payment of an administrative expense according to 11 U.S.C. § 503.

Name of Creditor (the person or other entity to whom the debtor owes money or property):

Name and address where notices should be sent:

Telephone number: email:

Name and address where payment should be sent (if different from above):

Telephone number: email:

PROOF OF CLAIM

COURT USE ONLY

❐ Check this box if this claim amends a previously filed claim.

Court Claim Number:

(If known)

Filed on:

❐ Check this box if you are aware that anyone else has filed a proof of claim relating to this claim.   Attach copy of statement giving particulars. 

Proof of Claim form - U.S. Courts