U.S. USDA Form usda-rd-1965-14
U S D A
Form RD 1965-14
(Rev. 8/98)
UNITED STATES BANKRUPTCY COURT FOR THE
DISTRICT OF
Case No. _____________________
In re )
)
)
)
____________________________________ , )
Debtor
PROOF OF CLAIM OF THE UNITED STATES OF AMERICA (Individual)
1. The undersigned, _______________________________________________________ of _______________________________________
(Office mailing address)
is the ________________________________ for the _______________________________ of ________________________________ , of the
(Title) (State/Country Name)
(State/Country)
United States Department of Agriculture, and has been duly authorized by the Secretary of Agriculture to make this proof claim on behalf
of the United States of America.
2. The debtor was at the filing of the petition initiating this case, and is still indebted to the United States of America, in the total sum of
$________________________________ . This consists of:
a. ______________________________ Unpaid principal which includes any advances indicated in Section c of this paragraph.
b. ______________________________ Unpaid interest accrued to ________________________________ (daily accrual thereafter of
$____________________________). This amount includes any interest on advances indicated
in Section c of this paragraph.
c. The following advances authorized by the securing instruments described in paragraph 3;
$_____________________________ advanced for _______________________________________________________________ .
$_____________________________ advanced for _______________________________________________________________ .
$_____________________________ advanced for _______________________________________________________________ .
$_____________________________ advanced for _______________________________________________________________ .
d. $_____________________________ Unpaid balance of judgment plus costs awarded by the judgment order as described in
paragraph 5.
e. $_____________________________ Interest credit granted that is subject to recapture pursuant to 42 USC 1490a(a)(1)(D).*
f. $_____________________________ Principal reduction attributed to subsidy*.
(*If borrower is presently receiving interest credit, these figures will increase during the period of the interest credit agreement.)
3.
The consideration for said debt is $_______________________________ originally loaned and/or advanced for the account of said
debtor or assumed by said debtor which loans or advances were made or insured by the United States of America. The loans are evidenced by
promissory notes or assumption agreements described as follows:
Date of Note Original Principal Amount
and are secured by the security instruments described on the reverse side of this form.
RD 1965-14 (Rev. 8/98)
Position 2
Security
Instrument
Date Filed
Volume/Book/Document No.
Page
Office where recorded or filed
County
Photocopies of the security instruments and promissory notes described in this paragraph are attached hereto (or cannot be attached hereto for
the reasons set forth in the statement attached hereto). Evidence of perfection of such security interests is also attached hereto. No security
interest is held for this claim except as set forth in these security instruments.
4.
The amount of all payments on this claim has been credited and deducted for the purpose of making this proof of claim.
5.
No judgment has been rendered on the claim except (indicate date, court, and amount of each judgment)___________________________
_________________________________________________________________________________________________________________ .
6.
This claim is not subject to any setoff or counter claim except __________________________________________________________ .
7.
This claim is a general unsecured claim except to the extent that the security interest, if any, described in paragraph 3 is sufficient to
satisfy the claim..
Check if applicable
8.
(
) The Government’s claim is secured only by real property which is the residence of the debtor(s).
9.
(
) As of the date of this Proof of Claim, payments of debtor(s) as stated in the note(s) are reduced under terms of a payment
subsidy agreement which expires on ______________________________________ . The extension and amount of further subsidy is subject
to Government regulations governing payment subsidy, 7 CFR 3550.
(
(
) Debtor’s monthly payment as reduced is $ _______________________________ per month.
) Debtor’s annual payment as reduced is $ ________________________________ per year.
10.
(Chapter 13 cases only). Included in the total claim set forth in paragraph 2 are arrearages in the amount of $______________________
as of the date of filing the petition.
UNITED STATES OF AMERICA
_________________________________________________
By: __________________________________________________
(Date)
UNITED STATES DEPARTMENT OF AGRICULTURE
THE HONORABLE
___________________________________________________
(Insert Agency Name)
BANKRUPTCY JUDGE
_____________________________________________
__________________________________________________
Please take notice that the undersigned is attorney for the United States of America in this matter and that service of all notices and papers
affecting this claim should be made upon the undersigned at the address given below, in addition to sending a copy of all such notices and papers
to the above referenced USDA Official at the address indicated above.
____________________________________________________
United States Attorney
_________________________________________________
Office and Post Office Address
By: _________________________________________________
Attorney for the United States
Penalty for presenting fraudulent claim: Fine —
of
not more than $5,000 or imprisonment for not more than 5 years or both.
Title 18, USC §152.