Smart Proof of Claim

________________________________________________________________________________

* Fill in this information to identify the case:
________________________________________________________________________________

Debtor: [[Debtor]]
United States Bankruptcy Court for the: Southern District of New York
Case number: [[Case Number]]
________________________________________________________________________________

|| Official Form 410 ||
_________________

PROOF OF CLAIM (04/16)
______________________________________________________________________________________________________

* 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? ||[[Creditor Name]]||

______________________________________________________________________________________________________
2. Has this claim been acquired from someone else? ||||
______________________________________________________________________________________________________
3. Where should notices and payments to the creditor be sent? ||[[Creditor Address]]||
* Federal Rule of Bankruptcy Procedure (FRBP) 2002(g)
______________________________________________________________________________________________________
4. Does this claim amend one already filed? ||||
______________________________________________________________________________________________________
5. Do you know if anyone else has filed a proof of claim for this claim? ||||
______________________________________________________________________________________________________
|| Part 2: Give Information About the Claim as of the Date the Case Was Filed ||
______________________________________________________________________________________________________
6. Do you have any number you use to identify the debtor? ||||
______________________________________________________________________________________________________
7. How much is the claim? ||$[[Claim Amount]]||

______________________________________________________________________________________________________
8. What is the basis of the claim? ||[[Claim Description]]||
* Examples: Goods sold, money loaned, lease, services performed, personal injury or wrongful death, or credit card.
* 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 secured? ||||
______________________________________________________________________________________________________
10. Is this claim based on a lease? ||||
______________________________________________________________________________________________________
11. Is this claim subject to a right of setoff? ||||
______________________________________________________________________________________________________
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.
* With regard to priority under 11 U.S.C. § 507(a)(4),(7): Amounts are subject to adjustment on 4/01/19 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.
I am: [[Description of Filer]].
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: [[Execution Date]]
{{signature of Creditor Signatory Email}}
________________
Print the name of the person who is completing and signing this claim:
[[Creditor Signatory Full Name]]
[[Creditor Signatory Title]]
[[Creditor Signatory Address]]
[[Creditor Signatory Phone Number]]
[[Creditor Signatory Notice Email Address]]