Official Form 410 "Proof of Claim"

What Is a Bankruptcy Proof of Claim?

Official Form 410, Proof of Claim, is a legal document completed by creditors in bankruptcy cases who need to stake their claims by submitting them to the bankruptcy court in a timely manner. This form allows you to be considered for payment - you will not be paid unless you specifically file a Proof of Claim approved by the bankruptcy court.

Alternate Names:

  • Bankruptcy Form 410;
  • Bankruptcy Proof of Claim.

This form was released by the U.S. Bankruptcy Court on April 1, 2019, with all previous editions obsolete. Download a fillable Bankruptcy Proof of Claim Form through the link below.

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Bankruptcy Form 410 Instructions

Follow these steps to fill out Bankruptcy Form 410:

  1. Identify the bankruptcy case - name the debtors, specify the court, and indicate the case number.
  2. Identify the claim. Name the current creditor - the individual or entity to be paid for this claim. State whether the claim was acquired from someone else and write down the addresses of the creditor.
  3. If the claim amends one already filed or you know someone else who has filed a proof of claim for this particular claim, answer "yes".
  4. Enter the number you use to identify the debtor and include the amount of the claim.
  5. Describe the basis of the claim and state whether all or part of the claim is secured by a lien on the property.
  6. If the claim based on a lease or subject to a right of setoff, answer "yes".
  7. If your claim is entitled to priority, check the appropriate box - domestic support obligations, penalties or taxes owed to the government, etc.
  8. Indicate your status - a creditor, creditor's authorized representative, trustee, debtor, guarantor, or another codebtor.
  9. Confirm the information in the form is true and correct, sign, and date the form. Record your contact information, and if you represent an entity, indicate the company and your title.

How to File a Proof of Claim in Bankruptcy Court?

Once the form is completed, attach copies of documentation that supports your claim: purchase orders, invoices, promissory notes, and security agreements. If your claim depends on a security interest in the debtor's residence, you need to file the following documents with Form 410:

When filing a Bankruptcy Proof of Claim, do not attach original documents and redact documents that identify the debtor or disclose health care information - you can only leave the last four digits of any social security number and the year of any individual's date of birth. Submit Official Form 410 to the clerk of the same bankruptcy court in which the bankruptcy case was filed.

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Download Official Form 410 "Proof of Claim"

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Fill in this information to identify the case:
Debtor 1
__________________________________________________________________
Debtor 2
________________________________________________________________
(Spouse, if filing)
__________
__________
United States Bankruptcy Court for the:
District of
__________ District of __________
Case number
___________________________________________
Official Form 410
Proof of Claim
04/19
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.
Part 1:
Identify the Claim
1. Who is the current
___________________________________________________________________________________________________________
creditor?
Name of the current creditor (the person or entity to be paid for this claim)
Other names the creditor used with the debtor
________________________________________________________________________
2. Has this claim been
No
acquired from
Yes. From whom?
______________________________________________________________________________________________________
someone else?
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
________________________
________________________
Contact phone
Contact phone
________________________
________________________
Contact email
Contact email
Uniform claim identifier for electronic payments in chapter 13 (if you use one):
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
4. Does this claim amend
No
one already filed?
Yes. Claim number on court claims registry (if known)
Filed on
________
________________________
MM
/ DD
/ YYYY
5. Do you know if anyone
No
else has filed a proof
Yes. Who made the earlier filing?
_____________________________
of claim for this claim?
Official Form 410
Proof of Claim
page 1
Fill in this information to identify the case:
Debtor 1
__________________________________________________________________
Debtor 2
________________________________________________________________
(Spouse, if filing)
__________
__________
United States Bankruptcy Court for the:
District of
__________ District of __________
Case number
___________________________________________
Official Form 410
Proof of Claim
04/19
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.
Part 1:
Identify the Claim
1. Who is the current
___________________________________________________________________________________________________________
creditor?
Name of the current creditor (the person or entity to be paid for this claim)
Other names the creditor used with the debtor
________________________________________________________________________
2. Has this claim been
No
acquired from
Yes. From whom?
______________________________________________________________________________________________________
someone else?
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
________________________
________________________
Contact phone
Contact phone
________________________
________________________
Contact email
Contact email
Uniform claim identifier for electronic payments in chapter 13 (if you use one):
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
4. Does this claim amend
No
one already filed?
Yes. Claim number on court claims registry (if known)
Filed on
________
________________________
MM
/ DD
/ YYYY
5. Do you know if anyone
No
else has filed a proof
Yes. Who made the earlier filing?
_____________________________
of claim for this claim?
Official Form 410
Proof of Claim
page 1
Part 2:
Give Information About the Claim as of the Date the Case Was Filed
6. Do you have any number
No
you use to identify the
Yes. Last 4 digits of the debtor’s account or any number you use to identify the debtor: ____ ____ ____ ____
debtor?
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.
______________________________________________________________________________
9. Is all or part of the claim
No
secured?
Yes. The claim is secured by a lien on property.
Nature of property:
Real estate. If the claim is secured by the debtor’s principal residence, file a Mortgage Proof of Claim
Attachment (Official Form 410-A) with this Proof of Claim.
Motor vehicle
Other. Describe:
_____________________________________________________________
Basis for perfection:
_____________________________________________________________
Attach redacted copies of documents, if any, that show evidence of perfection of a security interest (for
example, a mortgage, lien, certificate of title, financing statement, or other document that shows the lien has
been filed or recorded.)
Value of property:
$__________________
Amount of the claim that is secured:
$__________________
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:
$____________________
Annual Interest Rate (when case was filed) _______%
Fixed
Variable
10. Is this claim based on a
No
lease?
Yes. Amount necessary to cure any default as of the date of the petition.
$____________________
11. Is this claim subject to a
No
right of setoff?
Yes. Identify the property: ___________________________________________________________________
Official Form 410
Proof of Claim
page 2
12. Is all or part of the claim
No
entitled to priority under
Yes. Check one:
Amount entitled to priority
11 U.S.C. § 507(a)?
Domestic support obligations (including alimony and child support) under
A claim may be partly
$____________________
11 U.S.C. § 507(a)(1)(A) or (a)(1)(B).
priority and partly
nonpriority. For example,
Up to $3,025* of deposits toward purchase, lease, or rental of property or services for
in some categories, the
$____________________
personal, family, or household use. 11 U.S.C. § 507(a)(7).
law limits the amount
entitled to priority.
Wages, salaries, or commissions (up to $13,650*) earned within 180 days before the
$____________________
bankruptcy petition is filed or the debtor’s 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).
$____________________
Contributions to an employee benefit plan. 11 U.S.C. § 507(a)(5).
$____________________
Other. Specify subsection of 11 U.S.C. § 507(a)(__) that applies.
*
Amounts are subject to adjustment on 4/01/22 and every 3 years after that for cases begun on or after the date of adjustment.
Part 3:
Sign Below
The person completing
Check the appropriate box:
this proof of claim must
I am the creditor.
sign and date it.
FRBP 9011(b).
I am the creditor’s attorney or authorized agent.
If you file this claim
I am the trustee, or the debtor, or their authorized agent. Bankruptcy Rule 3004.
electronically, FRBP
I am a guarantor, surety, endorser, or other codebtor. Bankruptcy Rule 3005.
5005(a)(2) authorizes courts
to establish local rules
specifying what a signature
I understand that an authorized signature on this Proof of Claim serves as an acknowledgment that when calculating the
is.
amount of the claim, the creditor gave the debtor credit for any payments received toward the debt.
A person who files a
fraudulent claim could be
I have examined the information in this Proof of Claim and have a reasonable belief that the information is true
fined up to $500,000,
and correct.
imprisoned for up to 5
years, or both.
I declare under penalty of perjury that the foregoing is true and correct.
18 U.S.C. §§ 152, 157, and
3571.
Executed on date
_________________
MM / DD
/
YYYY
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
Contact phone
_____________________________
Email
____________________________________
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Official Form 410
Proof of Claim
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