Creditor's Claim Notice Form

CREDITOR'S CLAIM NOTICE FORM

Creditor Name:    Creditor Contact (phone/email):

Claim Against (Estate or Case Name):

Court/Jurisdiction:    Case Number:

Debtor/Respondent Name:    Date of Claim:

Recitals

WHEREAS, Creditor Name: asserts a debt or obligation owed by Debtor/Respondent Name: arising from the facts described below; and

WHEREAS, Creditor seeks to preserve and assert all rights, claims and remedies available under applicable law by providing notice of this Claim to the estate, trustee, or other case representative identified herein; and

WHEREAS, Creditor intends that this Notice constitute a formal claim for the amounts and relief set forth in this document and any attachments incorporated by reference.

NOW THEREFORE, Creditor hereby provides this Creditor's Claim Notice Form upon the terms and conditions set forth below.

1. Claim Summary

Nature of Claim:

Claim Type: Secured Unsecured Priority Administrative

2. Basis and Itemization of Claim

3. Security, Collateral and Setoff

Is the claim secured by collateral? Yes No

Does creditor assert a right of setoff or counterclaim? Yes No

4. Interest, Fees and Other Charges

Interest Rate Claimed (if any):

5. Certification and Representations

The undersigned Creditor hereby certifies and represents that the amounts set forth herein are justly due and owing under the instruments, agreements or obligations identified above; that these amounts are true and correct to the best of the undersigned's knowledge; and that the undersigned is authorized to file and prosecute this Claim on behalf of the Creditor. The undersigned further certifies that supporting documents identified above are true, authentic, and complete copies of the original documents in the possession or control of the Creditor.

Creditor acknowledges that submission of this Notice may be subject to applicable filing and service requirements and that failure to comply with such requirements may affect the allowance and treatment of the Claim.

6. Notices

All notices under this Claim shall be delivered to the addresses provided above and shall be effective upon receipt when delivered by hand, overnight courier, or when sent by certified mail, return receipt requested.

7. Governing Law; Miscellaneous Provisions

Governing Law: This Claim Notice and any dispute arising out of it shall be governed by and construed in accordance with the substantive laws of the jurisdiction identified in the Court/Jurisdiction field above, without regard to choice-of-law principles.

Entire Agreement: This document, together with its attachments and incorporated statements, constitutes the entire notice and agreement between the Creditor and the estate concerning the Claim and supersedes all prior communications and understandings with respect to the subject matter herein.

Severability: If any provision of this Claim Notice is held to be invalid, illegal or unenforceable, the remaining provisions shall remain in full force and effect and the invalid provision shall be reformed only to the extent necessary to make it valid and enforceable.

Amendments and Waiver: No amendment, modification or waiver of any provision of this Claim Notice shall be effective unless in writing and signed by an authorized representative of the party against whom enforcement is sought. No failure or delay in exercising any right shall operate as a waiver of that right.

Counterparts: This Claim 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. Signature and Certification

The undersigned certifies under penalty of perjury that the statements contained in this Claim Notice and in any attachments are true and correct to the best of the undersigned's knowledge, information and belief, and that the undersigned is authorized to execute this Claim on behalf of the Creditor identified herein.

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