B 10 (Official Form 10) (04/10)
United States Bankruptcy Court EASTERN District of MICHIGAN
Proof of Claim
In re (Name of Debtor):
Case Number:
David S Belzak,
10-23963
NOTE: This form should not be used to make a claim for an administrative expense arising after the commencement of the case. A "request" for
payment of an administrative expense may be filed pursuant to 11 U.S.C. ' 503.
Check this box to indicate that this claim
amends a previously filed claim.
Court Claim Number: ________________
Name of Creditor (The person or other entity to whom the debtor owes money or property):
(If known)
Filed on: _______________
JP Morgan Chase Bank NA successor by merger to Bank One NA
Name and Address Where Notices Should be Sent:
JP Morgan Chase Bank, N.A.
2901 Kinwest Pkwy
Irving, TX 75063-5812
Attn: Bankruptcy Department
Check this box if you are aware that
anyone else has filed a proof of claim
relating to your claim. Attach copy of
statement giving particulars.
Check this box if you are the debtor or
trustee in this case.
Name and Address Where Payment Should be Sent (If different from above):
5. Amount of claim Entitled to
Priority under 11 U.S.C 507(a). If
any portion of your claim falls in
one of the following categories,
check the box and state the
amount.
JP Morgan Chase Bank, N.A.
National Payment Services
PO Box 24785
Columbus, OH 43224
Specify the priority of the claim.
1. Amount of Claim at Time Case Filed:
53220.08
If all or part of your claim is secured, complete item 4 below; however, if all of your claim is unsecured, do not complete item 4.
If all or part of your claim is entitled to priority, complete item 5.
Check this box if claim includes interest or other charges in addition to the principal amount of claim. Attach itemized
statement of interest or charges.
2. Basis for Claim: Mortgage
(See instruction # 2 on reverse side
Wages, salaries, or commissions
(up to $11,725*), earned within
180 days before filing of the
bankruptcy petition or cessation
of the debtor's business,
whichever is earlier--11 U.S.C. '
507(a)(4).
___________
3. Last four digits of any number by which creditor identifies debtor: 3211
___
3a. Debtor may have scheduled account as: ___________________________________________________________
(See instruction #3a on reverse side)
Contributions to an employee
benefit plan---11 U.S.C. '
507(a)(5).
4. Secured Claim
Check the appropriate box if your claim is secured by a lien on property or a right of setoff and provide the requested
information.
Nature of property or right of setoff:
Real Estate Motor Vehicle Other
Describe:
Up to $2,600* of deposits toward
purchase, lease, or rental of
property or services for personal,
family, or household use---11
U.S.C. ' 507(a)(7).
Value of Property: $_______________________129000__ Annual Interest Rate _7_%
Amount of arrearage and other charges as of time case case filed included in secured claim.
if any $ _____1129.68__________ Basis for perfection: ___Trust
Amount of Secured Claim: $__________53220.08_
Domestic support obligations
under 11 U.S.C. ' 507(a)(1)(A) or
(a)(1)(B).
Deed_____
Taxes or penalties owed to
governmental units---11 U.S.C. '
507(a)(8).
Amount Unsecured: $_________0.00__
Other--Specify applicable
paragraph of -11 U.S.C. '
507(a)___________.
6. CREDITS: The amount of all payments on this claim has been credited for the purpose of making this proof of claim.
7. DOCUMENTS: Attach redacted copies of any documents that support the claim, such as promissory notes, purchase
orders, invoices, itemized statements of running accounts, contracts, judgments, mortgages, and security agreements. You
may also attach a summary. Attach redacted copies of documents providing evidence of perfection of a security interest.
You may also attach a summary.
Amount entitled to priority:
$____________
DO NOT SEND ORIGINAL DOCUMENTS. ATTACHED DOCUMENTS MAY BE DESTROYED AFTER SCANNING.
*Amounts are subject to adjustment on 4/1/10
and every 3 years thereafter with respect to cases
commenced on or after the date of adjustment.
If the documents are not available, please explain:
Date:
1/6/2011
FOR COURT USE ONLY
Signature: The person filing this claim must sign it. Sign and print name and title, if any, of the creditor or other person
authorized to file this claim and state address and telephone number if different from the notice address above. Attach copy of
power of attorney, if any.
/s/ Jonessa Cyrus
Telephone No: (866) 520-6447
Penalty for presenting fraudulent claim: Fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C.''152 and 3571
Case 10-23963-dob
Claim 15-1
Filed 01/19/11
Page 1 of 4
EXHIBIT A
TO PROOF OF CLAIM
CLAIMANT: JP Morgan Chase Bank NA successor by merger to Bank One NA
------- BANKRUPTCY CASE ---------------------------------------------------------------------------------------------------------CASE NUMBER: 10-23963
DEBTOR (S): David S Belzak,
LOAN NUMBER: XXXXXXXX 3211
------- SUMMARY -----------------------------------------------------------------------------------------------------------------------AS OF
10/26/2010
The principal amount owing on the above loan was:
$49858.03
Plus interest due in the amount of:
$536.01
Plus interest short balance of:
$0.00
Plus escrow advances of:
$0.00
Plus late charges of:
$525.4
Less buydown balance of:
$0.00
Less subsidy balance of:
$0.00
Less borrower subsidy balance of:
$0.00
Less forebearance suspense balance of:
$0.00
Less borrower suspense balance of:
$0.00
Less trustee suspense balance of:
$0.00
Less miscellaneous suspense balance of:
$0.00
Plus Deferred Interest of:
$2191.64
Plus NSF fee:
$25
Plus Annual fee:
$
Plus total expenses of:
$84
For a total due in the amount of:
$53220.08
------- ARREARAGES--------------------------------------------------------------------------------------------------------------------------Installment Payments:
$495.28
Late charges:
$525.4
Additional Interest
$
Unpaid Fees: (Annual/NSF fees)
$25
Expenses: Foreclosure fees:
$0
Bankruptcy fees:
$0
Loss mitigation fees:
$0.00
REO fees:
$0.00
Additional liens:
$0
Appraisal/BPO fees
$84
Property taxes:
$0
Property insurance:
$0
MI premiums:
$0.00
Utilities(water,etc.):
$0.00
Property Preservation:
$0
Title charges
$0
Filing fee
$0
Title report
$0
Total expenses:
$84
TOTAL ARREARAGE CLAIM:
$1129.68
The above figures represent the delinquency at the time of filing and do not reflect payments received after the date of
the filing of the bankruptcy
------- POST-PETITION----------------------------------------------------------------------------------------------------------The post-petition payments should be
$447.52
------- INSTALLMENT PAYMENT DETAIL----------------------------------------------------------------------------------------------10/20/2010 $495.28
------- LATE CHARGE DETAIL---------------------------------------------------------------------------------------------------------------
Case 10-23963-dob
Claim 15-1
Filed 01/19/11
Page 2 of 4
5/30/08 $0.40, 6/30/08 $25, 7/30/08 $25, 9/2/08 $25, 9/30/08 $25, 12/01/8 $25, 12/30/08 $25, 1/30/09 $25, 3/30/09 $25,
4/30/09 $25, 9/30/09 $25, 10/30/09 $25, 11/30/09 $25, 12/30/09 $25, 2/1/10 $25, 3/2/10 $25, 3/30/10 $25, 4/30/10 $25,
6/1/10 $25, 7/30/10 $25, 9/30/10 $25
Case 10-23963-dob
Claim 15-1
Filed 01/19/11
Page 3 of 4
US Bankruptcy Court Clerk
Re:David S Belzak,
Chapter 13
Case Number 10-23963
JP Morgan Chase Bank NA successor by merger to Bank One NA
Dear Clerk of the Court:
JP Morgan Chase Bank NA , , is filing a claim in the bankruptcy case referenced above. Enclosed are the
following:
1. Original Proof of Claim with attached supporting documents;
2. Two copies of the Proof of Claim; and
3. Self-addressed, stamped return envelope.
Please file the original Proof of Claim and acknowledge your receipt by date stamping one of the copies and
returning it in the envelope provided.
If you have any questions, please contact the bankruptcy account officer, listed below.
Thank you for your attention to this matter.
Sincerely,
Jonessa Cyrus
( 866) 520-6447
Case 10-23963-dob
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