N.H. Rev. Stat. Ann. § 359-P:5
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
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) No
1.______________________________ 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 _______________ %
Source. 2016, 293:2, eff. Aug. 20, 2016. 2017, 109:2, eff. June 8, 2017.