(no title)

Proof of Claim Submission

A proof of claim submission form for 128 WI

URL

This field is for validation purposes and should be left unchanged.

Debtor Name(Required)

Case Number(Required)

County of Filing(Required)

Date of Filing

Creditor Information

Creditor Name / Company(Required)

Mailing Address(Required)

City(Required)

State

Zip

Contact Name(Required)

Phone Number(Required)

Email Address(Required)

Debtor's Account Number(Required)

Claim Details

Type of Claim(Required)

Date Debt was Incurred

If nothing is owed, and/or this account has been paid, indicate here(Required)

Total Amount Claimed(Required)

Claim Classification(Required)

Unsecured

Secured

Priority Unsecured

No judgment has been rendered relating to this debt, except the case indicated below.

Wisconsin Court County

Court Case Number

The claim identified herein is included in the Affidavit of Debts. No interest, late charges, fees or penalties have been added after the filing date of the debtor’s petition.

Supporting Documentation

Supporting Documents

Drop files here or

Accepted file types: pdf, Max. file size: 10 MB.

Certification & Signature

I declare under penalty of perjury that the information provided in this Proof of Claim is true and correct to the best of my knowledge, information, and belief. I am authorized to file this claim on behalf of the creditor named above.

Printed Name(Required)

Title / Relationship to Creditor

Phone(Required)

Email(Required)

Is this an amended submission?(Required)

If you have submitted this proof of claim and are resubmitting it please choose Yes, otherwise No.

Date of Submission(Required)

Certification(Required)

I certify the above statement is true and accurate and I am authorized to submit this claim.

CAPTCHA