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MGive Information About the Claim as of the Date the Case Was Filed <br />6. Do you have any number <br />❑ No <br />you use to identify the <br />debtor? <br />❑ Yes Last 4 digits of the debtor's account or any number you use to identify the debtor <br />7 How much is the claim? <br />$ Does this amount include interest or other charges? <br />❑ No <br />❑ Yes Attach statement itemizing interest, fees, expenses, or other <br />charges required by Bankruptcy Rule 3001(c)(2)(A) <br />8 What is the basis of the <br />Examples Goods sold, money loaned, lease, services performed, personal injury or wrongful death, or credit card <br />claim? <br />Attach redacted copies of any documents supporting the claim required by Bankruptcy Rule 3001(c) <br />Limit disclosing information that is entitled to privacy, such as health care information <br />9. Is all or part of the claim <br />❑ No <br />secured? <br />❑ Yes. The claim is secured by alien on property. <br />Nature of property: <br />❑ Real estate If the claim is secured by the debtor's principal residence, file a Mortgage Proof of <br />Clain Attachment (Official Form 410-A) with this Proof of Claim <br />❑ Motor vehicle <br />❑ Other. Describe <br />Basis for perfection: <br />Attach redacted copies of documents, if any, that show evidence of perfection of a security interest (for <br />example, a mortgage, lien, certificate of title, financing statement, or other document that shows the lien <br />has been filed or recorded ) <br />Value of property: $ <br />Amount of the claim that is secured: $ <br />Amount of the claim that is unsecured: $ (The sum of the secured and unsecured <br />amount should match the amount in line 7 ) <br />Amount necessary to cure any default as of the date of the petition: $ <br />Annual Interest Rate (when case was filed) % <br />❑ Fixed <br />❑ Variable <br />10 Is this claim based on a <br />❑ No <br />lease? <br />❑ Yes Amount necessary to cure any default as of the date of the petition. $ <br />11 Is this claim subject to a <br />❑ No <br />right of setoff? <br />❑ Yes. Identify the property <br />Official Form 410 Proof of Claim 111111111111 111111111111 11111111111111111111111 11111 X111 <br />page 2 1042644160620183342010891 <br />