Bankruptcy Notice Form

Bankruptcy Notice Form

This Bankruptcy Notice Form is provided by Creditor Name: with principal address: to Debtor Name: whose address is: . Case Number: . Chapter: Chapter 7 Chapter 11 Chapter 13. Date of Petition: . Bankruptcy Court: . Chapter 7/11/13 Trustee: .

RECITALS

WHEREAS, Creditor Name: asserts that it holds or asserts a claim against Debtor in the amount of $ for: .

WHEREAS, Debtor filed a voluntary/involuntary petition under Chapter indicated above in the Bankruptcy Court identified above, thereby initiating the referenced bankruptcy case and invoking the protections and procedures of the Bankruptcy Code; and

WHEREAS, Creditor wishes to provide formal written notice of its claim, preserve its rights to file a proof of claim, and identify the Creditor contact and service address for all notices and pleadings.

NOW, THEREFORE, in consideration of the foregoing and the mutual covenants contained herein, the parties agree as follows:

1. NOTICE OF BANKRUPTCY FILING

Creditor hereby provides notice to all parties in interest that a petition was filed in the Bankruptcy Court listed above. This Notice is not a waiver of any right to contest the jurisdiction of the Court, to seek relief from the automatic stay, or to assert any setoff, recoupment or counterclaim.

2. STATEMENT OF CLAIM

Creditor's asserted claim (whether scheduled or unscheduled) arises from:

The approximate amount of the claim is $. Creditor reserves the right to amend or supplement this amount if supporting documentation later establishes a different amount.

3. EFFECT ON AGREEMENTS; AUTOMATIC STAY

The filing of the petition may invoke the automatic stay codified in the Bankruptcy Code. Nothing in this Notice constitutes consent by Creditor to stay relief, modification of payment terms, or alteration of any collateral rights. Creditor expressly reserves all rights to seek relief from the automatic stay, to pursue reclamation, to exercise setoff and to enforce any security interests to the fullest extent permitted by law.

4. PROOF OF CLAIM

If a deadline to file a proof of claim has been established, Creditor intends to timely file a proof of claim in the amount stated above unless otherwise ordered by the Court. Proof of Claim Deadline: . Creditor reserves the right to amend, supplement or withdraw any proof of claim as permitted by applicable law.

5. PRESERVATION OF RIGHTS

This Notice shall not be construed as a waiver of Creditor's rights to assert any claim, lien, security interest, administrative expense, or defense in any proceeding, including but not limited to objections to discharge, objections to exemptions, motions for relief from stay, or requests for adequate protection.

6. NOTICES

Preferred method of delivery: First-class mail Certified mail Hand delivery Email.

7. AMENDMENTS; WAIVER; COUNTERPARTS

This Notice may be amended only by a written instrument signed by the party to be charged. No waiver by any party of any breach or default shall be a waiver of any subsequent breach or default. This Notice may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

8. GOVERNING LAW

This Notice shall be governed by and construed in accordance with the laws of the state of , except to the extent superseded by the Bankruptcy Code and federal law applicable to bankruptcy proceedings.

9. ENTIRE AGREEMENT

This Notice constitutes the entire written notice and agreement between the parties with respect to the subject matter hereof and supersedes all prior written notices or understandings relating to the same.

10. SEVERABILITY

If any provision of this Notice is held to be invalid, illegal or unenforceable in any respect, such invalidity, illegality or unenforceability shall not affect any other provision hereof, and the remaining provisions shall remain in full force and effect.

11. AUTHORIZED REPRESENTATIVE

12. CERTIFICATION

The undersigned certifies under penalty of perjury that the information provided in this Notice is true and correct to the best of the undersigned's knowledge and belief, and that the undersigned is authorized to provide this Notice on behalf of the Creditor identified herein.

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