Your Proiority Unsecured Claims Continuation Page Official Form 106ef
Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page 1 of ___
Official Form 106E/F
Schedule E/F: Creditors Who Have Unsecured Claims 12/15
Be as complete and accurate as possible. Use Part 1 for creditors with PRIORITY claims and Part 2 for creditors with NONPRIORITY claims.
List the other party to any executory contracts or unexpired leases that could result in a claim. Also list executory contracts on Schedule
A/B: Property (Official Form 106A/B) and on Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G). Do not include any
creditors with partially secured claims that are listed in Schedule D: Creditors Who Have Claims Secured by Property . If more space is
needed, copy the Part you need, fill it out, number the entries in the boxes on the left. Attach the Continuation Page to this page. On the top of
any additional pages, write your name and case number (if known).
Part 1: List All of Your PRIORITY Unsecured Claims
1. Do any creditors have priority unsecured claims against you?
No. Go to Part 2.
Yes.
2. List all of your priority unsecured claims. If a creditor has more than one priority unsecured claim, list the creditor separately for each claim. For
each claim listed, identify what type of claim it is. If a claim has both priority and nonpriority amounts, list that claim here and show both priority and
nonpriority amounts. As much as possible, list the claims in alphabetical order according to the creditor's name. If you have m ore than two priority
unsecured claims, fill out the Continuation Page of Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.
(For an explanation of each type of claim, see the instructions for this form in the instruction booklet.)
Total claim Priority
amount
Nonpriority
amount
2.1
____________________________________________
Priority Creditor's Name
____________________________________________
Number Street
____________________________________________
____________________________________________
City State ZIP Code
Last 4 digits of account number ___ ___ ___ ___
$_____________ $___________ $____________
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply
Contingent
Unliquidated
Disputed
Type of PRIORITY unsecured claim:
Domestic support obligations
Taxes and certain other debts you owe the government
Claims for death or personal injury while you were
intoxicated
Other. Specify _________________________________
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
2.2
____________________________________________
Priority Creditor's Name
____________________________________________
Number Street
____________________________________________
____________________________________________
City State ZIP Code
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
Last 4 digits of account number ___ ___ ___ ___
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply
Contingent
Unliquidated
Disputed
Type of PRIORITY unsecured claim:
Domestic support obligations
Taxes and certain other debts you owe the government
Claims for death or personal injury while you were
intoxicated
Other. Specify _________________________________
$_____________ $___________ $____________
Debtor 1 __________________________________________________________________
First Name Middle Name Last Name
Debtor 2 ________________________________________________________________
(Spouse, if filing) First Name Middle Name Last Name
United States Bankruptcy Court for the: __________ District of __________
Case number ___________________________________________
(If known)
Fill in this information to identify your case:
Check if this is an
amended filing
__________ District of __________
Debtor 1 _______________________________________________________ Case number (if known) _____________________________________
First Name Middle Name Last Name
Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___
Part 1: Your PRIORITY Unsecured Claims ─ Continuation Page
After listing any entries on this page, number them beginning with 2.3, followed by 2.4, and so forth.
Total claim Priority
amount
Nonpriority
amount
____________________________________________
Priority Creditor's Name
____________________________________________
Number Street
____________________________________________
____________________________________________
City State ZIP Code
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
Last 4 digits of account number ___ ___ ___ ___
When was the debt incurred? ____________
As of the date you file, the claim is:
Check all that apply.
Contingent
Unliquidated
Disputed
Type of PRIORITY unsecured claim:
Domestic support obligations
Taxes and certain other debts you owe the government
Claims for death or personal injury while you were
intoxicated
Other. Specify _________________________________
$____________ $__________ $____________
____________________________________________
Priority Creditor's Name
____________________________________________
Number Street
____________________________________________
____________________________________________
City State ZIP Code
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
Last 4 digits of account number ___ ___ ___ ___
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Type of PRIORITY unsecured claim:
Domestic support obligations
Taxes and certain other debts you owe the government
Claims for death or personal injury while you were
intoxicated
Other. Specify _________________________________
$____________ $__________ $____________
____________________________________________
Priority Creditor's Name
____________________________________________
Number Street
____________________________________________
____________________________________________
City State ZIP Code
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
Last 4 digits of account number ___ ___ ___ ___
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Type of PRIORITY unsecured claim:
Domestic support obligations
Taxes and certain other debts you owe the government
Claims for death or personal injury while you were
intoxicated
Other. Specify _________________________________
$____________ $__________ $____________
Debtor 1 _______________________________________________________ Case number (if known) _____________________________________
First Name Middle Name Last Name
Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___
Part 2: List All of Your NONPRIORITY Unsecured Claims
3. Do any creditors have nonpriority unsecured claims against you?
No. You have nothing to report in this part. Submit this form to the court with your other schedules.
Yes
4. List all of your nonpriority unsecured claims in the alphabetical order of the creditor who holds each claim. If a creditor has more than one
nonpriority unsecured claim, list the creditor separately for each claim. For each claim listed, identify what type of claim it is. Do not list claims already
included in Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.If you have more than three nonpriority unsecured
claims fill out the Continuation Page of Part 2.
Total claim
4.1
_____________________________________________________________
Nonpriority Creditor's Name
_____________________________________________________________
Number Street
_____________________________________________________________
City State ZIP Code
Last 4 digits of account number ___ ___ ___ ___
$__________________
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Type of NONPRIORITY unsecured claim:
Student loans
Obligations arising out of a separation agreement or divorce
that you did not report as priority claims
Debts to pension or profit-sharing plans, and other similar debts
Other. Specify ______________________________________
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
4.2
_____________________________________________________________
Nonpriority Creditor's Name
_____________________________________________________________
Number Street
_____________________________________________________________
City State ZIP Code
Last 4 digits of account number ___ ___ ___ ___
$__________________
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Type of NONPRIORITY unsecured claim:
Student loans
Obligations arising out of a separation agreement or divorce
that you did not report as priority claims
Debts to pension or profit-sharing plans, and other similar debts
Other. Specify ______________________________________
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
4.3
_____________________________________________________________
Nonpriority Creditor's Name
_____________________________________________________________
Number Street
_____________________________________________________________
City State ZIP Code
Last 4 digits of account number ___ ___ ___ ___
$_________________
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Type of NONPRIORITY unsecured claim:
Student loans
Obligations arising out of a separation agreement or divorce
that you did not report as priority claims
Debts to pension or profit-sharing plans, and other similar debts
Other. Specify ______________________________________
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
Debtor 1 _______________________________________________________ Case number (if known) _____________________________________
First Name Middle Name Last Name
Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___
Part 2: Your NONPRIORITY Unsecured Claims ─ Continuation Page
After listing any entries on this page, number them beginning with 4.4, followed by 4.5, and so forth.
Total claim
_____________________________________________________________
Nonpriority Creditor's Name
_____________________________________________________________
Number Street
_____________________________________________________________
City State ZIP Code
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
Last 4 digits of account number ___ ___ ___ ___
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Type of NONPRIORITY unsecured claim:
Student loans
Obligations arising out of a separation agreement or divorce that
you did not report as priority claims
Debts to pension or profit-sharing plans, and other similar debts
Other. Specify________________________________
$____________
_____________________________________________________________
Nonpriority Creditor's Name
_____________________________________________________________
Number Street
_____________________________________________________________
City State ZIP Code
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
Last 4 digits of account number ___ ___ ___ ___
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Type of NONPRIORITY unsecured claim:
Student loans
Obligations arising out of a separation agreement or divorce that
you did not report as priority claims
Debts to pension or profit-sharing plans, and other similar debts
Other. Specify________________________________
$____________
_____________________________________________________________
Nonpriority Creditor's Name
_____________________________________________________________
Number Street
_____________________________________________________________
City State ZIP Code
Who incurred the debt? Check one.
Debtor 1 only
Debtor 2 only
Debtor 1 and Debtor 2 only
At least one of the debtors and another
Check if this claim is for a community debt
Is the claim subject to offset?
No
Yes
Last 4 digits of account number ___ ___ ___ ___
When was the debt incurred? ____________
As of the date you file, the claim is: Check all that apply.
Contingent
Unliquidated
Disputed
Type of NONPRIORITY unsecured claim:
Student loans
Obligations arising out of a separation agreement or divorce that
you did not report as priority claims
Debts to pension or profit-sharing plans, and other similar debts
Other. Specify________________________________
$____________
Debtor 1 _______________________________________________________ Case number (if known) _____________________________________
First Name Middle Name Last Name
Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___
Part 3: List Others to Be Notified About a Debt That You Already Listed
5. Use this page only if you have others to be notified about your bankruptcy, for a debt that you already listed in Parts 1 or 2. For
exampl
e, if a collection agency is trying to collect from you for a debt you owe to someone else, list the original creditor in Pa
rts 1 or
2, the
n list the collection agency here.
Similarly, if you have more than one creditor for any of the debts that you listed in Parts 1 or 2, list the
additional creditors here. If you do not have additional persons to be notified for any debts in Parts 1 or 2, do not fill out or submit this page.
____________
_________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one) : Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured Claims
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one) : Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one) : Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one) : Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one) : Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one) : Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___ ___ ___ ___
_____________________________________________________
Name
_____________________________________________________
Number Street
_____________________________________________________
_____________________________________________________
City State ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor?
Line _____ of (Check one) : Part 1: Creditors with Priority Unsecured Claims
Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___ ___ ___ ___
Debtor 1 _______________________________________________________ Case number (if known) _____________________________________
First Name Middle Name Last Name
Official Form 106E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___
Part 4: Add the Amounts for Each Type of Unsecured Claim
6. Total the amounts of certain types of unsecured claims. This information is for statistical reporting purposes only. 28 U.S.C. § 159.
A
dd the amounts for each type of unsecured cl
aim.
Total claim
Total claims
from Part 1
6a. Domestic support obligations 6a.
$_________________________
6b. Taxes and certain other debts you owe the
government 6b.
$_________________________
6c. Claims for death or personal injury while you were
intoxicated
6c.
$_________________________
6d. Other. Add all other priority unsecured claims.
Write that amount here. 6d.
+ $_________________________
6e. Total. Add lines 6a through 6d. 6e.
$_________________________
Total claim
Total claims
from Part 2
6f. Student loans 6f.
$_________________________
6g. Obligations arising out of a separation agreement
or divorce that you did not report as priority
claims 6g.
$_________________________
6h. Debts to pension or profit-sharing plans, and other
similar debts 6h.
$_________________________
6i. Other. Add all other nonpriority unsecured claims.
Write that amount here. 6i.
+ $_________________________
6j. Total. Add lines 6f through 6i. 6j.
$_________________________
Source: https://fill.io/US-Courts-Form-B106EF-Schedule-E-F-Creditors-Who-Have-Unsecured-Claims
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