File Survivor Claim Form - The Roman Catholic Diocese of Albany, New York

File a Confidential Survivor Proof Of Claim

IMPORTANT NOTICE OF REDACTION RESPONSIBILITY: All filers must redact: Social Security or taxpayer-identification numbers; dates of birth; names of minor children; and financial account numbers, in compliance with Fed. R. Bankr. P. 9037. This requirement applies to all documents, including attachments.

IMPORTANT WARNING: A person who files a fraudulent claim could be fined up to $500,000, imprisoned for up to 5 years, or both. 18 U.S.C. §§ 152, 157, and 3571.

ACCEPT THE ABOVE RULES TO PROCEED:

I understand that, if I file, I must comply with the redaction rules. I have read this notice.

Read the instructions before filling out this form.

A person who files a fraudulent claim could be fined up to $500,000, imprisoned for up to 5 years, or both. 18 U.S.C. §§ 152, 157, and 3571.

Filers must leave out or redact information that is entitled to privacy on this form or on any attached documents. Attach redacted copies of any documents that support the claim, such as promissory notes, purchase orders, invoices, itemized statements of running accounts, contracts, judgments, mortgages, and security agreements. Do not send original documents; they may be destroyed after scanning. If the documents are not available, explain in an attachment.

Fill in all the information about the claim as of the date the case was filed. That date is on the notice of bankruptcy (Form 309) that you received.

Part 1: Identify the Claim

1. Who is the current creditor?

Name of the current creditor (the person or entity to be paid for this claim)

Other names the creditor used with the debtor

2. Has this claim been acquired from someone else?

No Yes

3. Where should notices and payments to the creditor be sent?

Federal Rule of Bankruptcy Procedure (FRBP) 2002(g)

Should payments to the creditor be sent to a different address?

Uniform claim identifier for electronic payments in chapter 13 (if you use one):

4. Does this claim amend one already filed?

No Yes

5. Do you know if anyone else has filed a proof of claim for this claim?

No Yes

Attachments / Documents

Attach redacted copies of any documents that show that the debt exists, a lien secures the debt, or both.

Also attach redacted copies of any documents that show perfection of any security interest or any assignment or transfers of the debt. In addition to the documents, a summary may be added. Federal Rule of Bankruptcy Procedure (called "Bankruptcy Rule") 3001(c) and (d). (See instructions and the definition of "redacted".)

Attachments:

Necessary documentation can be attached to the Proof of Claim before the information for the form is submitted
Attachments to the Proof of Claim are required to be PDF files.
Multiple attachments to the Proof of Claim are permitted.
Do not upload a completed Proof of Claim form as an attachment to this filing. Attaching a completed Proof of Claim will result in multiple versions of the form being filed (the electronically created proof of claim form plus the proof of claim attached). If filing an Amended Proof of Claim, the attachment of the previously filed claim is allowed.

Click below to attach documentation (see instructions) .

Attach…

Part 3: Sign Below

The person completing this proof of claim must sign and date it. FRBP 9011(b).

If you file this claim electronically, FRBP 5005(a)(2) authorizes courts to establish local rules specifying what a signature is.

A person who files a fraudulent claim could be fined up to $500,000, imprisoned for up to 5 years, or both. 18 U.S.C. §§ 152, 157, and 3571.

Select the appropriate option:

I am the creditor.

I am the creditor’s attorney or authorized agent.

I am the trustee, or the debtor, or their authorized agent. Bankruptcy Rule 3004.

I am a guarantor, surety, endorser, or other codebtor. Bankruptcy Rule 3005.

I understand that an authorized signature on this Proof of Claim serves as an acknowledgment that when calculating the amount of the claim, the creditor gave the debtor credit for any payments received toward the debt.

I have examined the information in this Proof of Claim and have a reasonable belief that the information is true and correct.

I declare under penalty of perjury that the foregoing is true and correct.

Executed on date 9/10/2025

Print the name of the person who is completing and signing this claim:

When submitting your Proof of Claim in this case, the Court strongly encourages you to complete this Survivor Claim Form, which the Court has approved. Submitting the Survivor Claim Form will help streamline the process of identifying claims and all applicable insurance coverage and expedite a distribution to creditors.

Uncheck if you do not wish to complete the Survivor Claim Form.

Survivor Claim Form

Please read all questions and instructions carefully and respond to each request for information to the best of your ability. If you have an attorney, you should complete this form with the assistance of counsel.

Part 1: Confidentiality

The information you share will be kept strictly confidential. You may indicate below that you waive this confidentiality.

Regardless of whether or not you waive confidentiality, this form and the information in it may be provided, pursuant to confidentiality procedures approved by the Bankruptcy Court, to the Diocese, certain insurers of the Diocese, the Official Committee of Unsecured Creditors (the “Creditors Committee”) and/or the Official Committee of Tort Claimants (the “Tort Committee”), their respective counsel, the United States Trustee, and to such other persons as the Bankruptcy Court may authorize.

Please be assured that these parties have agreed and are required to keep your information strictly confidential.

Check only one below:

I wish to keep my identity and this proof of claim CONFIDENTIAL.

I authorize my name, identity and this proof of claim (together with any exhibits and attachments) to be made PUBLICLY AVAILABLE AND PART OF THE PUBLIC RECORD.

Print Name

Date: 9/10/2025

If you do not check either box, if you check both boxes, or if you do not provide your name and signature, your claim and this form will remain confidential.

Part 2: Identifying Information

A. Survivor Claimant

First Name

Middle Initial

Last Name

Suffix (if any)

Street and Mailing Address

City

State

ZIP Code

Country (if other than USA)

(If party is incapacitated, is a minor or is deceased, please provide the address of the legal representative submitting the claim. If you are in jail or prison, list your current address).

Telephone No(s):

Home

Work

Cell

(If you are represented by counsel, you may provide your attorney’s work phone number instead of your own.)

Email Address

(If you are represented by counsel, you may provide your attorney’s email instead of your own.)

Social Security Number (last four digits only)

If you are in jail or prison, your identification number and location of incarceration

May the Diocese or the Tort Committee and their respective counsel of record in this chapter 11 case leave voicemails for you regarding your claim?

Yes No

May the Diocese or the Tort Committee and their respective counsel of record in this chapter 11 case send confidential information to your email?

Yes No

Birth Date

Have you been known by any other names (including maiden name, if applicable)?

B. Survivor Claimant’s Attorney (if any)

Check if you have an attorney

Law Firm Name

Attorney's Name

Address Line 1

City

State

ZIP Code

Country (leave blank for the US)

Phone #

Fax #

Part 3: Nature of Complaint

Note: If you have previously filed a lawsuit against the Diocese in State or Federal Court, please attach the complaint and respond to the questions below.

a. Were you sexually abused by more than one person?

Yes No

b. Who committed the acts of sexual abuse against you?

Please identify each person who sexually abused you. Individuals identified in this section will be referred to as the “abuser” in questions below. If applicable, you may identify more than one abuser. Please provide the complete name(s) of each abuser to the best of your recollection. If you do not know the name(s) of each abuser, please identify them by title, position or other description and provide as much information about that individual as you recall.

c. How did you know the abuser?

For example, was the abuser at your church, school or part of another group with which you were involved? Was the abuser a relative or family friend? Please include how you were introduced to the abuser if you know.

d. If the abuser was affiliated with a church, parish, school, or Diocesan organization, please identify each church, parish, school or organization.

e. Where did the sexual abuse take place?

Please be specific and complete all relevant information to the best of your recollection, including the names of locations and addresses, if known. If the abuse occurred in more than one location, please provide all relevant information concerning each location including the city and state and names of Parishes, schools and other religious organizations where the abuse took place. Please also provide the number of instances of abuse at each location.

f. When did the sexual abuse first take place?

Please be as specific as possible. If you do not recall the exact date, provide as much information as possible, including the year and season (fall, winter, spring, or summer, or school year and grade).) Please include, to the extent you know, your age when the abuse began.

g. How old you were when the sexual abuse began and ended?

If you do not recall the exact date, please try to provide as much information as possible, such as the year, your age and season (fall, winter, spring, or summer, or school year and grade).

h. Please describe the nature of the abuse.

If you are able, please specify what happened (e.g., the circumstances, approximate number of occurrences, frequency, duration, and type(s) of sexual abuse). Please provide as much detail as you recall. You may attach additional pages if needed.

i. Have you experienced injury and/or damages because of the act or acts of sexual abuse described above?

Please provide as much detail as possible. For example, describe any injuries or damages, as well as any effect on your emotions, education, employment, personal relationships, health, or faith.

j. Have you ever asserted a claim against the Diocese, or against any entity or individual other than the Diocese (including, but not limited to, any parish, church, school, or other organization) relating to the sexual abuse described in this claim?

If you have, please state when you asserted the claim, against whom the claim was asserted, the manner in which the claim was asserted (for example, a complaint made to law enforcement, a lawsuit or demand letter, participation in the Diocese’s Independent Mediation Assistance Program (IMAP) or a similar program sponsored by an entity other than the Diocese, an informal request for compensation, etc.), and the result of such claim (including, for example, whether such claim resulted in a settlement or was adjudicated and, if so, the terms of any non-confidential settlement or the outcome of such adjudication).

k. Did you tell anyone of the about the sexual abuse and, if so, whom did you tell?

If you did tell anyone, what did you tell that person? You do not need to disclose any communications you had with an attorney.

Attachments / Documents

If you wish to attach additional documents to this Confidential Survivor Supplement, please use the Attachments sections above.

Part 4: Certification

Under penalty of perjury, I declare the foregoing statements to be true and correct to the best of my knowledge.

Print name

Relationship to the Survivor

If you are signing the claim on behalf of a minor, decedent or incapacitated person, please state your relationship to the Survivor Claimant.

Date: 9/10/2025

Acknowledge you are a human

Penalty for presenting fraudulent claim: Fine of up to $500,000 or imprisonment for up to 5 years, or both.
18 U.S.C. §§ 152, 157, and 3571.

File a Confidential Survivor Proof Of Claim

Part 1: Identify the Claim

1. Who is the current creditor?

2. Has this claim been acquired from someone else?

3. Where should notices and payments to the creditor be sent?

4. Does this claim amend one already filed?

5. Do you know if anyone else has filed a proof of claim for this claim?

Part 2: Give Information About the Claim as of the Date the Case Was Filed

6. Do you have any number you use to identify the debtor?

7. How much is the claim?

Does this amount include interest or other charges?

8. What is the basis of the claim?

9. Is all or part of the claim secured?

10. Is this claim based on a lease?

11. Is this claim subject to a right of setoff?

12. Is all or part of the claim entitled to priority under 11 U.S.C. § 507(a)?

Attachments / Documents

Part 3: Sign Below

The person completing this proof of claim must sign and date it. FRBP 9011(b).

A person who files a fraudulent claim could be fined up to $500,000, imprisoned for up to 5 years, or both. 18 U.S.C. §§ 152, 157, and 3571.

Select the appropriate option:

Executed on date 9/10/2025

Print the name of the person who is completing and signing this claim:

Survivor Claim Form

Part 1: Confidentiality

Part 2: Identifying Information

Part 3: Nature of Complaint

Attachments / Documents

Part 4: Certification

Acknowledge you are a human