Official Form 104 "For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims Against You and Are Not Insiders"

What Is Official Form 104?

This is a legal form that was released by the United States Bankruptcy Court on December 1, 2015 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2015;
  • The latest available edition released by the United States Bankruptcy Court;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Official Form 104 by clicking the link below or browse more documents and templates provided by the United States Bankruptcy Court.

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Download Official Form 104 "For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims Against You and Are Not Insiders"

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Fill in this information to identify your case:
Debtor 1
__________________________________________________________________
First Name
Middle Name
Last Name
Debtor 2
________________________________________________________________
(Spouse, if filing)
First Name
Middle Name
Last Name
__________ District of __________
__________
__________
United States Bankruptcy Court for the:
District of
Case number
___________________________________________
(If known)
Check if this is an
amended filing
Official Form 104
For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest
Unsecured Claims Against You and Are Not Insiders
12/15
If you are an individual filing for bankruptcy under Chapter 11, you must fill out this form. If you are filing under Chapter 7, Chapter 12, or
Chapter 13, do not fill out this form. Do not include claims by anyone who is an insider. Insiders include your relatives; any general partners;
relatives of any general partners; partnerships of which you are a general partner; corporations of which you are an officer, director, person in
control, or owner of 20 percent or more of their voting securities; and any managing agent, including one for a business you operate as a sole
proprietor. 11 U.S.C. § 101. Also, do not include claims by secured creditors unless the unsecured claim resulting from inadequate collateral
value places the creditor among the holders of the 20 largest unsecured claims.
Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct
information.
Part 1:
List the 20 Unsecured Claims in Order from Largest to Smallest. Do Not Include Claims by Insiders.
Unsecured claim
1
What is the nature of the claim? ____________________________
$____________________________
__________________________________________
As of the date you file, the claim is:
Check all that apply.
Creditor’s Name
Contingent
__________________________________________
Unliquidated
Number
Street
Disputed
__________________________________________
None of the above apply
__________________________________________
City
State
ZIP Code
Does the creditor have a lien on your property?
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
Contact
-
Value of security:
$_____________________
____________________________________
Contact phone
Unsecured claim
$_____________________
2
What is the nature of the claim? ____________________________
$____________________________
__________________________________________
As of the date you file, the claim is:
Check all that apply.
Creditor’s Name
Contingent
__________________________________________
Unliquidated
Number
Street
Disputed
__________________________________________
None of the above apply
__________________________________________
City
State
ZIP Code
Does the creditor have a lien on your property?
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
Contact
-
Value of security:
$_____________________
____________________________________
Contact phone
Unsecured claim
$_____________________
Official Form 104
For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims
page 1
Fill in this information to identify your case:
Debtor 1
__________________________________________________________________
First Name
Middle Name
Last Name
Debtor 2
________________________________________________________________
(Spouse, if filing)
First Name
Middle Name
Last Name
__________ District of __________
__________
__________
United States Bankruptcy Court for the:
District of
Case number
___________________________________________
(If known)
Check if this is an
amended filing
Official Form 104
For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest
Unsecured Claims Against You and Are Not Insiders
12/15
If you are an individual filing for bankruptcy under Chapter 11, you must fill out this form. If you are filing under Chapter 7, Chapter 12, or
Chapter 13, do not fill out this form. Do not include claims by anyone who is an insider. Insiders include your relatives; any general partners;
relatives of any general partners; partnerships of which you are a general partner; corporations of which you are an officer, director, person in
control, or owner of 20 percent or more of their voting securities; and any managing agent, including one for a business you operate as a sole
proprietor. 11 U.S.C. § 101. Also, do not include claims by secured creditors unless the unsecured claim resulting from inadequate collateral
value places the creditor among the holders of the 20 largest unsecured claims.
Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct
information.
Part 1:
List the 20 Unsecured Claims in Order from Largest to Smallest. Do Not Include Claims by Insiders.
Unsecured claim
1
What is the nature of the claim? ____________________________
$____________________________
__________________________________________
As of the date you file, the claim is:
Check all that apply.
Creditor’s Name
Contingent
__________________________________________
Unliquidated
Number
Street
Disputed
__________________________________________
None of the above apply
__________________________________________
City
State
ZIP Code
Does the creditor have a lien on your property?
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
Contact
-
Value of security:
$_____________________
____________________________________
Contact phone
Unsecured claim
$_____________________
2
What is the nature of the claim? ____________________________
$____________________________
__________________________________________
As of the date you file, the claim is:
Check all that apply.
Creditor’s Name
Contingent
__________________________________________
Unliquidated
Number
Street
Disputed
__________________________________________
None of the above apply
__________________________________________
City
State
ZIP Code
Does the creditor have a lien on your property?
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
Contact
-
Value of security:
$_____________________
____________________________________
Contact phone
Unsecured claim
$_____________________
Official Form 104
For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims
page 1
Debtor 1
_______________________________________________________
Case number
_____________________________________
(if known)
First Name
Middle Name
Last Name
Unsecured claim
3
What is the nature of the claim? ____________________________
__________________________________________
$____________________________
Creditor’s Name
As of the date you file, the claim is:
Check all that apply.
__________________________________________
Number
Street
Contingent
Unliquidated
__________________________________________
Disputed
None of the above apply
__________________________________________
City
State
ZIP Code
Does the creditor have a lien on your property?
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
Contact
-
Value of security:
$_____________________
____________________________________
Contact phone
Unsecured claim
$_____________________
4
$____________________________
What is the nature of the claim? ____________________________
__________________________________________
Creditor’s Name
As of the date you file, the claim is:
Check all that apply.
__________________________________________
Contingent
Number
Street
Unliquidated
__________________________________________
Disputed
None of the above apply
__________________________________________
Does the creditor have a lien on your property?
City
State
ZIP Code
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
-
Contact
Value of security:
$_____________________
____________________________________
Unsecured claim
$_____________________
Contact phone
5
$____________________________
What is the nature of the claim? ____________________________
__________________________________________
Creditor’s Name
As of the date you file, the claim is:
Check all that apply.
__________________________________________
Contingent
Number
Street
Unliquidated
__________________________________________
Disputed
None of the above apply
__________________________________________
Does the creditor have a lien on your property?
City
State
ZIP Code
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
Contact
-
Value of security:
$_____________________
____________________________________
Unsecured claim
$_____________________
Contact phone
6
$____________________________
__________________________________________
What is the nature of the claim? ____________________________
Creditor’s Name
As of the date you file, the claim is:
Check all that apply.
__________________________________________
Contingent
Number
Street
Unliquidated
__________________________________________
Disputed
None of the above apply
__________________________________________
Does the creditor have a lien on your property?
City
State
ZIP Code
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
Contact
-
Value of security:
$_____________________
____________________________________
Unsecured claim
$_____________________
Contact phone
7
$____________________________
What is the nature of the claim? ____________________________
__________________________________________
Creditor’s Name
As of the date you file, the claim is:
Check all that apply.
Contingent
__________________________________________
Number
Street
Unliquidated
__________________________________________
Disputed
None of the above apply
__________________________________________
Does the creditor have a lien on your property?
City
State
ZIP Code
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
Contact
-
Value of security:
$_____________________
____________________________________
Unsecured claim
$_____________________
Contact phone
Official Form 104
For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims
page 2
Debtor 1
_______________________________________________________
Case number
_____________________________________
(if known)
First Name
Middle Name
Last Name
Unsecured claim
8
$____________________________
__________________________________________
What is the nature of the claim? ____________________________
Creditor’s Name
As of the date you file, the claim is:
Check all that apply.
__________________________________________
Contingent
Number
Street
Unliquidated
__________________________________________
Disputed
None of the above apply
__________________________________________
Does the creditor have a lien on your property?
City
State
ZIP Code
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
Contact
-
Value of security:
$_____________________
____________________________________
Unsecured claim
$_____________________
Contact phone
9
$____________________________
__________________________________________
What is the nature of the claim? ____________________________
Creditor’s Name
As of the date you file, the claim is:
Check all that apply.
__________________________________________
Contingent
Number
Street
Unliquidated
__________________________________________
Disputed
None of the above apply
__________________________________________
Does the creditor have a lien on your property?
City
State
ZIP Code
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
Contact
-
Value of security:
$_____________________
____________________________________
Unsecured claim
$_____________________
Contact phone
10
$____________________________
What is the nature of the claim? ____________________________
__________________________________________
Creditor’s Name
As of the date you file, the claim is:
Check all that apply.
__________________________________________
Contingent
Number
Street
Unliquidated
__________________________________________
Disputed
None of the above apply
__________________________________________
Does the creditor have a lien on your property?
City
State
ZIP Code
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
-
Contact
Value of security:
$_____________________
____________________________________
Unsecured claim
$_____________________
Contact phone
11
$____________________________
__________________________________________
What is the nature of the claim? ____________________________
Creditor’s Name
As of the date you file, the claim is:
Check all that apply.
__________________________________________
Contingent
Number
Street
Unliquidated
__________________________________________
Disputed
None of the above apply
__________________________________________
City
State
ZIP Code
Does the creditor have a lien on your property?
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
Contact
-
Value of security:
$_____________________
____________________________________
Unsecured claim
$_____________________
Contact phone
12
$____________________________
What is the nature of the claim? ____________________________
__________________________________________
As of the date you file, the claim is:
Check all that apply.
Creditor’s Name
Contingent
__________________________________________
Unliquidated
Number
Street
Disputed
__________________________________________
None of the above apply
Does the creditor have a lien on your property?
__________________________________________
City
State
ZIP Code
No
Yes. Total claim (secured and unsecured):
$_____________________
-
__________________________________________
Value of security:
$_____________________
Contact
Unsecured claim
$_____________________
____________________________________
Contact phone
Official Form 104
For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims
page 3
Debtor 1
_______________________________________________________
Case number
_____________________________________
(if known)
First Name
Middle Name
Last Name
Unsecured claim
13
$____________________________
__________________________________________
What is the nature of the claim? ____________________________
Creditor’s Name
As of the date you file, the claim is:
Check all that apply.
__________________________________________
Contingent
Number
Street
Unliquidated
__________________________________________
Disputed
None of the above apply
__________________________________________
Does the creditor have a lien on your property?
City
State
ZIP Code
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
Contact
-
Value of security:
$_____________________
____________________________________
Unsecured claim
$_____________________
Contact phone
14
$____________________________
__________________________________________
What is the nature of the claim? ____________________________
Creditor’s Name
As of the date you file, the claim is:
Check all that apply.
__________________________________________
Contingent
Number
Street
Unliquidated
__________________________________________
Disputed
None of the above apply
__________________________________________
Does the creditor have a lien on your property?
City
State
ZIP Code
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
Contact
-
Value of security:
$_____________________
____________________________________
Unsecured claim
$_____________________
Contact phone
15
$____________________________
What is the nature of the claim? ____________________________
__________________________________________
Creditor’s Name
As of the date you file, the claim is:
Check all that apply.
__________________________________________
Contingent
Number
Street
Unliquidated
__________________________________________
Disputed
None of the above apply
__________________________________________
Does the creditor have a lien on your property?
City
State
ZIP Code
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
-
Contact
Value of security:
$_____________________
____________________________________
Unsecured claim
$_____________________
Contact phone
16
$____________________________
__________________________________________
What is the nature of the claim? ____________________________
Creditor’s Name
As of the date you file, the claim is:
Check all that apply.
__________________________________________
Contingent
Number
Street
Unliquidated
__________________________________________
Disputed
None of the above apply
__________________________________________
Does the creditor have a lien on your property?
City
State
ZIP Code
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
Contact
-
Value of security:
$_____________________
____________________________________
Unsecured claim
$_____________________
Contact phone
17
$____________________________
What is the nature of the claim? ____________________________
__________________________________________
Creditor’s Name
As of the date you file, the claim is:
Check all that apply.
Contingent
__________________________________________
Number
Street
Unliquidated
__________________________________________
Disputed
None of the above apply
__________________________________________
Does the creditor have a lien on your property?
City
State
ZIP Code
No
Yes. Total claim (secured and unsecured):
$_____________________
__________________________________________
-
Contact
Value of security:
$_____________________
____________________________________
Unsecured claim
$_____________________
Contact phone
Official Form 104
For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims
page 4
Debtor 1
_______________________________________________________
Case number
_____________________________________
(if known)
First Name
Middle Name
Last Name
Unsecured claim
18
What is the nature of the claim? ____________________________
$____________________________
__________________________________________
Creditor’s Name
As of the date you file, the claim is:
Check all that apply.
__________________________________________
Contingent
Number
Street
Unliquidated
__________________________________________
Disputed
None of the above apply
__________________________________________
Does the creditor have a lien on your property?
City
State
ZIP Code
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
Contact
-
Value of security:
$_____________________
____________________________________
Unsecured claim
$_____________________
Contact phone
What is the nature of the claim? ____________________________
19
$____________________________
__________________________________________
Creditor’s Name
As of the date you file, the claim is:
Check all that apply.
__________________________________________
Contingent
Number
Street
Unliquidated
__________________________________________
Disputed
None of the above apply
__________________________________________
City
State
ZIP Code
Does the creditor have a lien on your property?
No
__________________________________________
Yes. Total claim (secured and unsecured):
$_____________________
Contact
-
Value of security:
$_____________________
____________________________________
Contact phone
Unsecured claim
$_____________________
What is the nature of the claim? ____________________________
20
$____________________________
As of the date you file, the claim is:
Check all that apply.
Contingent
__________________________________________
Unliquidated
Creditor’s Name
Disputed
__________________________________________
None of the above apply
Number
Street
__________________________________________
Does the creditor have a lien on your property?
No
__________________________________________
City
State
ZIP Code
Yes. Total claim (secured and unsecured):
$_____________________
-
Value of security:
$_____________________
__________________________________________
Unsecured claim
$_____________________
Contact
____________________________________
Contact phone
Part 2:
Sign Below
Under penalty of perjury, I declare that the information provided in this form is true and correct.
______________________________________________
______________________________________________
Signature of Debtor 1
Signature of Debtor 2
_________________
_________________
Date
Date
MM /
DD
/
YYYY
MM /
DD /
YYYY
Official Form 104
For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims
page 5
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