TN 23 (02-08)

A. List of Documents

The documents required for filing a Proof of Claim are:

• Notice of bankruptcy (3 copies), and

• Proof of Claim (original and 3 copies), and

• Certificate of Indebtedness (original and 3 copies) and

• Claims Collection Litigation Report (original and 2 copies).

B. Procedure - Preparation of Documents

1. Official Form 410

The Official Form 410 is the authorized bankruptcy form used to file a Proof of Claim. To obtain the form, use the Internet Site: http://www.uscourts.gov/sites/default/files/form_b_410_16.pdf. The form has separate entries for where to send notices and where to send payment.

2. Certificate of Indebtedness

Prepare the Certificate of Indebtedness on plain bond (in the format in GN 02215.260) for the signature of the ARC, PCO for the PSC or Associate Commissioner, OCO. Include the following information:

• The actual overpayment amount;

• The basis for the debt claim with pertinent citations (i.e., the section of the act giving rise to the debt and in general terms the provisions of that section). Include information relating to a failure to report or any other material fact; and

• The months overpaid, the amount paid, any amounts refunded or adjusted and the outstanding balance.

3. Claims Collection Litigation Report

Prepare a Claims Collection Litigation Report in the format indicated in GN 02215.270. Follow GN 02215.168 for completion of specific items.

IMPORTANT: Partial redaction of the SSN (the last 4 digits) is required on all three documents. Also, do not display the name of a minor child for a Title II debt.

4. Assembly and Disposition of Documents

1. Assemble 3 sets of documents identified with a coversheet for each set indicating for whom the set is intended.

   Set No. 1 - For U.S. Attorney

   • Notice of bankruptcy (original, if available)

   • Original and 1 copy of Proof of Claim

   • Original and 1 copy of Certificate of Indebtedness

   • Original Claims Collection Litigation Report

   Set No. 2 - Chief Counsel's File

   • Copy of notice of bankruptcy

   • Copy of Proof of Claim

   • Copy of Certificate of Indebtedness

   • Copy of Claims Collection Litigation Report

   Set No. 3 - For inclusion in SSA files

   • Copy of notice of bankruptcy

   • Copy of Proof of Claim

   • Copy of Certificate of Indebtedness

   • Copy of Claims Collection Litigation Report

2. Send sets 1 and 2 of bankruptcy documents to the RCC for review.

CAUTION: Do not send a claims folder unless specifically requested .by the Chief Counsel.