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Submit a Claim

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Contact Information – Step 1 of 7

Select matter *

Who is the current creditor? *

Name of the current creditor (the person or entity to be paid for this claim). Include any other names the creditor may have used with the debtor.

Contact for the creditor *

First

Last

Creditor mailing address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Is this an amended claim? *

Yes
No

Does this claim amend a previously submitted claim?

How much is the claim? *

How much is the creditor owed as of March 2, 2024 (the “Assignment Date”)?

What is the basis of the claim? *

Goods sold
Services performed
Equipment lease
Real estate lease
Money loaned
Equity interest
Other

If other, what is the basis of the claim? *

What is the type of claim? *

Secured
Priority
Unsecured
Equity interest

Secured Claims

Select the nature of property or right to setoff for this secured claim. *

Real estate
Personal property
Mother vehicle
Other

If other, please explain. *

What is the basis for perfection? *

At the end of this entry, please upload copies of documents, if any, that show evidence of perfection of a security interest (for example, a mortgage, lien, certificate of title, financing statement, or other document that shows the lien has been filed or recorded.)

What is the annual interest rate? Fixed or Variable? *

Priority Claims

Select the nature of this priority claim. *

Wages, salaries, bonuses, severance, or commissions earned
Contributions to an employee benefit plan
Taxes or penalties owed to governmental units
Other

If other, please explain. *

What is the basis for this priority claim? *

At the end of this entry, please upload copies of documents, if any, that show evidence supporting this claim.

Unsecured Claims

What is the basis for the unsecured claim? *

At the end of this entry, please upload copies of documents, if any, that show support of this claim.

Equity Claims

Number of shares held *

Basis/Value per share *

Type *

Common
Preferred

At the end of this entry, please upload copies of documents, if any, that show evidence supporting this claim.

E-Signature

Check the appropriate box. *

I am the creditor.
I am the creditor’s authorized agent.
I am a guarantor, surety, endorser, or other codebtor.

Name of individual responsible for filing this claim *

First

Last

Title *

Company *

Phone *

Email *

BY MY SELECTING "I AGREE" BELOW, I DECLARE UNDER PENALTY OF PERJURY, UNDER THE LAWS OF THE STATE OF DELAWARE, THAT THE INFORMATION PROVIDED HEREIN AND ATTACHED HERETO IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. *

I agree

File Upload

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Please upload copies of documents, if any, that show evidence supporting this claim.

Additional comments

To print and mail a claim, please click here.

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