Completing a Proof of Claim Form

Name of debtor:

Write the name of the person or company that has filed bankruptcy and owes you payment.

Case number:

Enter the case number from the bankruptcy notice. If you didn't receive a notice, enter the debtor's Social Security number or taxpayer identification number.

Name of creditor:

For all claims, enter UC Regents as the name of the creditor.

Name and address where notices should be sent:

For all claims, enter the following:
University of California, San Diego
Department / Division
9500 Gilman Drive, Mail code
La Jolla, CA 92093-0951

Attn:  Submitter

Telephone number

Check boxes:

• Check box if others also filed a proof of claim on this matter: Leave this box empty.
• Check box if you never received notices from the court on this case: Check the box if this is the first notice you received on this case.
• Check box if the address you listed differs from the address the court has: Check this box. Even though UCSD uses a central address, the bankrupt company may provide a specific department address or physical address.

Account or other number by which creditor identifies debtor:

If you use an account number, invoice number, or other identifier for the claim, enter it here.

If this claim replaces or amends a previously filed claim:

If this takes the place of or changes a Proof of Claim already filed, check the appropriate box and list the appropriate date filed.

Note: You can amend a previous Proof of Claim, if you:

• Over- or under-estimated your claim
• Omitted a portion of your claim
• Have been paid for your claim

Check the box, note that you’re amending it here and list the date filed. As long as your previous claim was well documented and filed in good faith, you won’t be penalized.

• Basis for claim: Check the box that correctly describes what payment is owed for (goods, services, etc.)
• Date debt was incurred: Enter the date the product was purchased or the service was used.
• If court judgment, date obtained: If the claim is based on a state court judgment, write the judgment date here.
• Total amount of claim at time case was filed: Enter the dollar amount of money owed here.
  • If all or part of claim is secured, complete Item 5 or 6 below: See further explanation in 5 and 6.
  • Check this box if claim includes interest or other charges: After checking the box, attach a document itemizing the interest and additional charges.
• Secured claim: A claim is secured if the one seeking payment has a collateral interest in the debtor’s property (real estate, a vehicle, a television set or other property). Then the creditor can be paid from that property before creditors who don’t have liens on the property. Most of UCSD’s claims are NOT secured.
  • Check this box if your claim is secured by collateral (including a right of setoff). Setoff occurs when the debtor and creditor both owe each other money or property and they offset one another. If the debtor claims that UCSD owes him money or property, there may be a setoff and UCSD might not file a proof of claim.
  • Check whether the collateral is real estate, motor vehicle or another item. If other, describe what it is.
  • Value of collateral: Write in dollar amount here.
  • Amount of arrearage and other charges included in secured claim: Fill in the total dollar amount owed here.
• Unsecured priority claim: If a claim isn't secured by collateral, it's an unsecured claim. Some unsecured claims have priority over others. Common types of priority claims are listed on the form.
  • Check this box if you believe your claim is an unsecured priority claim.
  • Amount entitled to priority: Write the total amount owed here.
  • Specify the priority of the claim: Choose the boxed category that best reflects your type of claim.
• Credits: Write nothing here. When the form is signed, you are stating under oath that all payments have been credited and properly deducted from the balance owed.
• Supporting documents: Attach copies (not originals) of contracts, purchase orders, invoices, etc. Attach explanation if there are too many documents to attach or documents aren’t available.

• Date: Write in the date the form is signed.
• Sign and print name and title of authorized party: An authorized party, usually the department manager or principal investigator, signs the form. Be sure they print their name and title. You do not need to attach a copy of power of attorney.