Debtor
_______________________________________________________
Case number
_____________________________________
(if known)
Name
Column A
Column B
Additional Page
Part 1:
Amount of claim
Value of collateral
that supports this
Do not deduct the value
claim
of collateral.
Copy this page only if more space is needed. Continue numbering the lines sequentially from the
previous page.
2._
Creditor’s name
Describe debtor’s property that is subject to a lien
__________________________________________
___________________________________________________
$__________________
$_________________
___________________________________________________
Creditor’s mailing address
___________________________________________________
________________________________________________________
Describe the lien
________________________________________________________
__________________________________________________
Creditor’s email address, if known
Is the creditor an insider or related party?
No
_________________________________________
Yes
Is anyone else liable on this claim?
Date debt was incurred
__________________
No
Last 4 digits of account
Yes. Fill out Schedule H: Codebtors (Official Form 206H).
number
___ ___ ___ ___
As of the petition filing date, the claim is:
Do multiple creditors have an interest in the
Check all that apply.
same property?
Contingent
No
Unliquidated
Yes. Have you already specified the relative
Disputed
priority?
No. Specify each creditor, including this
creditor, and its relative priority.
_______________________________
_______________________________
_______________________________
Yes. The relative priority of creditors is
specified on lines _____
2._
Creditor’s name
Describe debtor’s property that is subject to a lien
__________________________________________
___________________________________________________
$__________________
$_________________
___________________________________________________
Creditor’s mailing address
___________________________________________________
________________________________________________________
Describe the lien
________________________________________________________
__________________________________________________
Creditor’s email address, if known
Is the creditor an insider or related party?
No
_________________________________________
Yes
Is anyone else liable on this claim?
Date debt was incurred
__________________
No
Last 4 digits of account
Yes. Fill out Schedule H: Codebtors (Official Form 206H).
number
___ ___ ___ ___
As of the petition filing date, the claim is:
Do multiple creditors have an interest in the
Check all that apply.
same property?
Contingent
No
Unliquidated
Yes. Have you already specified the relative
Disputed
priority?
No. Specify each creditor, including this
creditor, and its relative priority.
_______________________________
_______________________________
_______________________________
Yes. The relative priority of creditors is
specified on lines _____
Official Form 206D
Additional Page of Schedule D: Creditors Who Have Claims Secured by Property
page ___ of ___