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Give Information About the Claim as of the Date the Case Was Filed <br /> 6 Do you have any number ❑ No <br /> you use to identify the ❑Yes.Last 4 digits of the debtor's account or any number you use to identify the debtor <br /> debtor? <br /> 7 How much is the claim? $ .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(cX2)(A) <br /> 8 What Is the basis of the 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 ail or part of the claim CI No <br /> secured? ❑Yes. The claim is secured by a lien 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 Claim <br /> Attachment(Official Form 410-A)with this Proof of Claim <br /> ❑ Motor vehicle <br /> ❑ Other Descnbe. _ <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 has <br /> 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 /> amounts 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 /> 10.1s this claim based on a ❑ No <br /> lease? <br /> ❑Yes.Amount necessary to cure any default as of the date of the petition. $ <br /> 11.1s this claim subject to a ❑ No <br /> right of setoff? <br /> ❑Yes.Identify the property: <br /> 1 <br /> I <br /> Official Form 410 Proof of Claim page 2 <br /> 046762 72304046808026 <br />