Proof of Claim Template (Official Form 410)

United States Bankruptcy Court
District of [District]

In re: [Debtor Name(s)]
Case No.: [Number]

Part 1: Identify the Claim

1. Who is the current creditor? [Name]
2. Has this claim been acquired from someone else? ☐ Yes ☐ No – If yes, from whom?
3. Where should notices be sent? [Address, phone, email]
4. Does this claim amend a previously filed proof of claim? ☐ Yes ☐ No – Claim number: [ ]
5. Does this claim secure a right to setoff? ☐ Yes ☐ No – Explain.

Part 2: Claim Amount

6. Amount of claim as of petition date: $[Amount].
7. Interest, fees, other charges included? ☐ Yes (provide itemized statement) ☐ No.

Part 3: Basis of Claim

8. Basis for claim (e.g., goods sold, money loaned, services, credit card, judgment).

Part 4: Secured Claim

9. Is claim secured by property? ☐ Yes ☐ No. If yes, describe collateral and attach proof of lien.
10. Value of collateral: $[Value].
11. Amount of secured claim: $[Amount].
12. Amount unsecured: $[Amount].
13. Nature of lien: ☐ Real estate mortgage ☐ Statutory lien ☐ Security interest ☐ Judgment lien ☐ Other.
14. Is collateral property insured? ☐ Yes (attach certificate) ☐ No.

Part 5: Priority Claim

15. Is claim entitled to priority under 11 U.S.C. § 507(a)? ☐ No ☐ Yes – specify type:
    - ☐ Domestic support obligations (§ 507(a)(1))
    - ☐ Wages, salaries (§ 507(a)(4))
    - ☐ Taxes (§ 507(a)(8))
    - ☐ Other priority: [Describe]
16. Amount of priority claim: $[Amount].

Part 6: Supporting Documentation

17. Attach redacted copies of any documents supporting the claim (invoices, contracts, judgments, security agreements). Explain if documents not available.

Part 7: Sign and Date

• I am the creditor or authorized agent.
• I have examined the information in this Proof of Claim and it is true and correct to the best of my knowledge.

Signature: ____ Date: __
Name: [Printed Name]
Title: [Title]
Company: [Creditor Name]
Address: [Address]
Phone: [Phone]
Email: [Email]

Penalty for presenting fraudulent claim: Fine up to $500,000, imprisonment up to 5 years, or both (18 U.S.C. §§ 152, 157, 3571).