I.A victim eligible for recovery assistance under RSA 359-P:3 may file an application for recovery assistance with the attorney or administrator on the following form: Financial Resources Mortgage, Inc and CL&M, Inc. Victims Indemnification Application
Name _______________________________________
Address _____________________________________
______________________________________
Phone_______________________________________
E-mail_______________________________________
Social Security No.____________________________
I.) Proof of Claim Federal Bankruptcy Court Case 09-14565-JMD and 09-14566-JMD date filed ____________________ Loans or Mortgages claimed (copy attached)
1.________________________________________ Amount $ __________2.________________________________________ Amount $ __________3.________________________________________ Amount $ __________4.________________________________________ Amount $ __________5.________________________________________ Amount $ __________6.________________________________________ Amount $ __________7.________________________________________ Amount $ __________8.________________________________________ Amount $ __________9.________________________________________ Amount $ __________10.________________________________________ Amount $ __________ Total Proof of Claim Amount $___________
II.) Were you a defendant in case no. 09-1184-JMD? Yes No Were you dismissed from the case? Yes No
III.) Did you settle with the Trustee? Yes No Did you make a payment to the Trustee for the benefit of the bankruptcy estates to settle with the Trustee? Yes No Amount $___________
IV. List any additional payments to the trustee as a result of any mortgage foreclosed, sold, or repaid as a condition of your settlement. Example: Agreed to split proceeds 80/20 with Trustee. 1.__________________________________________ _ Amount $_____________2.___________________________________________ Amount $_____________3.___________________________________________ Amount $_____________4.___________________________________________ Amount $_____________5.___________________________________________ Amount $_____________ Post settlement payments to Trustee Amount $_____________
V. Did you retain 100% ownership of any mortgages as a result of settlement? Yes (list below) No1.__________________________________________ Amount $______________2.___________________________________________ Amount $______________3.___________________________________________ Amount $______________4.___________________________________________ Amount $______________5.___________________________________________ Amount $______________ Total Retained 100% ownership $_______________
VI. List any payment from the Trustee on any mortgage he or she foreclosed on, sold, or received repayment of principal and from which proceeds were agreed to be split with you as a result of settlement. 1.___________________________________________ Amount $_______________2.___________________________________________ Amount $_______________3.___________________________________________ Amount $_______________4.___________________________________________ Amount $_______________5.___________________________________________ Amount $_______________ Total Split Proceeds received from Trustee post settlement $_______________
VII. Final Distribution of Bankruptcy Estate by Trustee received by you $___________VIII. Total Interest received from FRM or CL&M January 2006 through November 2009 $ ___________ (attach form 1040 and Schedule B, Interest and Dividends, for 2006-2009)
Calculate Loss:
A.Total Section I. Proof of Claim $_____________ Total Section III. Settlement Payment $_____________
Total Section IV. Proceed split payment to Trustee $_____________
Total A. $_____________
B.Total Section V. 00% Retained Mortgages $_____________ Total Section VI. Proceed Split receipt from Trustee $_____________
Total Section VII. Final Distribution from Trustee $_____________
Total Section VIII. Interest Received $_____________
Total of any other awards not otherwise accounted for $_____________
Total B. $_____________
C.Total A minus Total B. Allowable Loss $_____________ Signature____________________________
Date_____________________
Signed under penalty of perjury
For administration purposes only
Grand Total All Losses submitted $_____________
(name)__________________ allowable loss submitted $_____________
Percent of Grand Total submitted _______________%