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- #4000
- @001 State the name of the claimant:
- @400 Enter the District where case is pending:
- @401 Enter the State where case is pending:
- @402 State the case number: @403 State the name of the debtor (bankrupt):
- #4001/#4002/#4003/#4004 This claim is made by:
- An individual, filing on his own behalf
- An partnership, by a partner
- A corporation by an employee/officer
- Any of the above through an agent
- #if#4001
- @404 State the street address of claimant:
- @405 Please enter the state of claimant's residence:
- @406 Please state the zip code of claimant:
- #endif
- #if#4002
- @407 State the name of partner making claim:
- @408 Please state the street address of partner:
- @409 Please enter the state of partner's residence:
- @410 Please state the zip code of partner:
- @412 Please state names of other partners:
- @413 Please state business address of partnership:
- #endif
- #if#4003
- @490 Please state the name of corporate officer making claim:
- @491 Please state the street address of officer:
- @492 Please enter the state of officer's residence:
- @493 Please state the zip code of corporate officer:
- @494 Please state the title of corporate officer making claim:
- @495 Please enter the state where corporation is organized:
- #endif
- #if#4004
- @420 Please state the name of the agent making claim:
- @421 Please state the address of agent:
- #endif
- #4005
- @430 Please state the amount due:
- @431 Please state the ground of liability:
- @432 Please state the principal amount of debt:
- @433 Please state any additional charges (interest, etc.):
- @434 Please state the reason for additional charges if any):
- @435 Please state due date, if debt not yet due:
- @436 Please state date and court of judgment if any:
- @437 Please state if there is any counterclaim or setoff: