Official Form 410 Proof of Claim page 3
12. Is all or part of the claim
entitled to priority under
11 U.S.C. § 507(a)?
A claim may be partly
priority and partly
nonpriority. For example,
in some categories, the
law limits the amount
entitled to priority.
Amount entitled to priority
$________
____________
$____________________
$____________________
$____________________
$____________________
No
Yes. Check one:
Domestic support obligations (including alimony and child support) under
11 U.S.C. § 507(a)(1)(A) or (a)(1)(B).
Up to $3,025* of deposits toward purchase, lease, or rental of property or services for
personal, family, or household use. 11 U.S.C. § 507(a)(7).
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
this proof of claim must
sign and date it.
FRBP 9011(b).
If you file this claim
electronically, FRBP
5005(a)(2) authorizes courts
to establish local rules
specifying what a signature
is.
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.
Check the appropriate box:
I am the creditor.
I am the creditor’s attorney or authorized agent.
I am the trustee, or the debtor, or their authorized agent. Bankruptcy Rule 3004.
I am a guarantor, surety, endorser, or other codebtor. Bankruptcy Rule 3005.
I understand that an authorized signature on this Proof of Claim serves as an acknowledgment that when calculating the
amount of the claim, the creditor gave the debtor credit for any payments received toward the debt.
I have examined the information in this Proof of Claim and have a reasonable belief that the information is true
and correct.
I declare under penalty of perjury that the foregoing is true and correct.
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 ____________________________________