Translation of the proof of
insolvency claim form
For explanatory purposes only: Please use
only the German version of the form to submit
your proof of claim!
Proof of Insolvency Claim
Proofs of claim must be submitted with the insolvency administrator
(insolvency / bankruptcy trustee / creditors' custodian), not with the court.
Please also see the court's instruction leaflet on filing a proof of claim.
Insolvency Debtor:
Insolvency Court:
File No.:
Creditor:
Creditor's Attorney / Representative /
Agent:
Power of Attorney enclosed / to be
submitted ASAP
Bank Account:
Reference No.:
File No.:
Insolvency Claims
Please list each individual claim separately. If there is not enough space on this form
to list all of your claims, please attach a separate sheet setting forth the remaining
claims in the same manner as shown hereunder.
First Principal Claim − non-subordinated claim pursuant
to Insolvency Code section 38 (please estimate amount, if
necessary)
Interest, at a maximum up to and including the day prior
to the opening of insolvency proceedings
Percentage points above
Base rate
€, as from
[date]
% of
€, as from
[date]
Costs and Expenses incurred prior to the opening of
insolvency proceedings
Sum Total
€
Second Principal Claim − non-subordinated claim
pursuant to Insolvency Code section 38 (please estimate
amount, if necessary)
Interest, at a maximum up to and including the day prior
to the opening of insolvency proceedings
Percentage points above
Base rate
€, as from
[date]
% of
€, as from
[date]
Costs and Expenses incurred prior to the opening of
insolvency proceedings
Sum Total
€
Translation of the proof of insolvency claim form used in North Rhine Westphalia, Hamburg and the Saarland,
as of July 1, 2014
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Subordinated Claims (Insolvency Code section 39)
A proof of claim for subordinated claims may only be filed if the court has expressly called
upon the creditors to do so (see, Insolvency Code section 174 para. 3). Please indicate
each claim's tier within the statutory order set forth in Insolvency Code section 39 by
checking the appropriate box. Beginning with subordinated claim tier no. 3, interest and
costs / expenses must be set forth separately and linked with the corresponding principal
claim (see, Insolvency Code section 39 para. 3).
1. Subordinated claim pursuant to s. 39 para. 1 no. 1
2. Subordinated claim pursuant to s. 39 para. 1 no. 2
3. Subordinated claim pursuant to s. 39 para. 1 no. 3
4. Subordinated claim pursuant to s. 39 para. 1 no. 4
5. Subordinated claim pursuant to s. 39 para. 1 no. 5
6. Subordinated claim pursuant to s. 39 para. 2
Interest (s 39 para. 3) re: subordinated tier 3 – 4 – 5 – 6
Costs (s 39 para. 3) re: subordinated tier 3 – 4 – 5 – 6
Sum Total of Subordinated Claims
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Preferential settlement of the claim based on a security is being sought, as well as a prorata settlement to the extent that the security should fail to satisfy the claim.
Yes, see enclosed explanation and proof of existing security.
No
The claims filed herein should expressly be exempted from the discharge of the
debtor's residual claims pursuant to Insolvency Code section 302 because:
The claims against the debtor
arise in connection with an intentional tort;
constitute spousal alimony / child support arrears intentionally withheld by the
debtor contrary to his existing payment obligations;
constitute tax obligations in connection with which the debtor has finally and
conclusively been found guilty of a tax crime within the meaning of German
General Tax Code (Abgabenordnung) section 370, 373 or 374.
The reasons why the undersigned creditor believes one or more of his / her claims to be
claims within the meaning of Insolvency Code section 174 para. 2 are to be explained
more fully in a separate attachment enclosed with this proof of claim.
No
Grounds and Particulars as to the Basis of the Claims Filed (e.g., supply of goods, rent,
loan, repair services, wages, promissory note, damages, etc.)
All documents evidencing and supporting the claims are enclosed (ideally in
duplicate):
(Place)
(Date)
(Signature and Company Seal, if any)
Please return in duplicate to:
Rechtsanwalt Dr. A. Ringstmeier als Insolvenzverwalter, Brückenstraße 21, 50667 Köln
Translation of the proof of insolvency claim form used in North Rhine Westphalia, Hamburg and the Saarland,
as of July 1, 2014