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CLAIMS COLLECTION LITIGATION REPORT (CCLR)

1. Agency Claim No._________________ 2. Date ______________

THE CLAIM AT A GLANCE

3. To: (Use Complete Address) 4. From: (Use Complete Address)BAgency/Sub-Agency 

 

 

5. Debtor=s Name &Address:*

* (If a FORECLOSURE, Insert address of property here so claim will be referred to USAO where property is located.)

6. Debtor=s SSN / EIN: 7. Default Date:

8. SOL Expiration Date

 

9. Basis for SOL Expiration Date:

10. Referred for:

Enforced Collection

Judgment Lien Only

Renew Judgment Lien Only

Renew Judgment Lien &

Enforce Collection

Program Enforcement

Foreclosure Only

Foreclosure & Deficiency Judgment

File Proof of Claim Only

Comments -

Other - real property lien 

11. Amount of Claim:

a. Total Principal Due 

 Total Interest Due 

 Interest Through Date 

c. Total Administrative

 Charges Due 

d. Total Penalty

 Charges Due 

e. Total Amount

 of Claim 

DOJ Concurrence for:

Compromise (4 CFR 103) 12.

 

 Annual Rate 

of Interest 

Suspension (4 CFR 104)

Termination (4 CFR 105)

13. Compromise Amount ____________ 

or % ________ 

10a. DEBTOR IN BANKRUPTCY:

 Chapter: 7 11 12 13 Unknown

14. Basis of Claim:

Claim evidenced by note, guaranty, or surety obligation:

OR

Claim not evidenced by note but by the following statute

or regulation;

 

15. Agency Contact:

Name: ........................................................................

Phone No.:.................................................................

 (FTS and Commercial)
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(CCLR)

Agency Claim No 

THE INDIVIDUAL DEBTOR

16. Debtor=s Full Name: 17. A.K.A.:

18. Date of Birth: 19. Home Phone No. (Include Area Code):

20. Employer=s Name and Address: 21. Debtor=s Job Title:

22. Work Phone No. (Include Area Code):

23. Debtor=s Salary: $_________________

Gross Weekly Monthly

 Net Biweekly Annually

24. Best place for Marshal to serve process by personal

delivery: (Do NOT give P.O. Box) Home Work

Other (Specify):

25. Name of person who verified above data, date

verified, and how verified: 

THE COMPANY DEBTOR

: If this claim is to collect a debt owed by an entity other than an individual person, such as a company, partnership,

corporation, etc., additional information will be required. In such cases, insert the data called for in blocks 26-33 below and

use CCLR Supplementary Data Sheets to furnish additional information, as appropriate.

 26. Debtor=s Full Name 27. Debtor=s Address:

28. D.B.A.: 29. Phone No. (Include Area Code):

30. Type of Business: 31. Date & State of Incorporation:
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(CCLR)

Agency Claim No. 

32. Name, Address & Phone Number (Include Area Code)

of Service Agent:

33. Name of person who verified above company debtor

data, date verified, and how verified:

CO-DEBTOR(S)/GUARANTOR(S)/CO-SIGNER(S)

34. Full Name(s): 35. SSN / EIN:

36. A.K.A.: 37. Date of Birth:

38. Home Address/Business & Phone No. (Include Area

Code)

39. Employer=s Name & Address:

40. Work Phone No. (Include Area Code): 43. Best place for Marshal to serve process by personal

delivery: (Do NOT give P.O. Box) Home Work

Other (Specify):

41. Co-Debtor=s Job Title:

42. Salary: $_________________

 Gross Weekly Monthly

 Net Biweekly Annually

44. Basis of Liability: 45. Name of person who verified above data on codebtor(s)/guarantor(s)/co-signer(s), date verified, and

how verified:
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(CCLR)

Agency Claim No. 

FORECLOSURES

: If this claim is referred for foreclosure only or foreclosure and a deficiency judgment, the following additional data will be

required. In such cases, insert the date called for in blocks 46 - 50 below and use CCLR Supplementary Data Sheets to

furnish additional information, as appropriate.

 46. 

 

 Debtor=s Address: 47. Mortgage Recording Information:

County 

Date of Recording 

Volume (Liber) .........................................................

Page Number (Folio) ................................................

48. Property Occupancy:

Debtor Resides on Property: Yes No 

Property is Abandoned: Yes No 

Property is occupied by tenant: Yes No 

49. If recovery of chattels is included in the foreclosure,

list the chattels here and provide more detailed

information on the CCLR Supplementary Data Sheet:

50. List other Federal liens against property:

 

DEBTOR=S ABILITY TO PAY

51. The debtor/co-debtor owns or is buying the following

real estate or other property (cars, boats, etc.):

52. Assets in which the Government has a secured

interest:

53. Other Assets: (savings/checking accounts, provide bank and/or credit union name(s) and address(s) and account

number(s); deceased debtor=s estate, provide administrator/executor information; other sources of income):

NAME OF BANK ACCOUNT NUMBER ACCOUNT TYPE
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(CCLR)

Agency Claim No. 

AGENCY CLAIM HISTORY

54. Date of last demand for payment to debtor and

summary of debtor=s response:

55. Details of any compromise or settlement offers made

by, or to, the debtor and any responses thereto:

56. Summary of collection actions taken by agency:

ADDITIONAL INFORMATION

57. For HHS loans: Medical or other professional

association locator data:

58. Additional agency comments:

59. AGENCY CHECK LIST: CCLR package must contain:

In General:

] CCLR

] Certificate of Indebtedness

Credit Report

] Payment History, if any

] Original Notes or Other Evidence of Debt,

Including Assignments, If Any

Summary of Collection Actions Taken by Agency

Debtor in Bankruptcy:

] Proof of Claim, or Copy Thereof, Attached

For Foreclosures:

] CCLR

] Credit Report

] Original Promissory Note

] Original Real Estate Mortgage

] Original Statement of Account/Affidavit

of Amount Due

] Title Evidence, If Available

] Directions to Property If No Street Address

Available

] Chattel Lien Searches If Chattels Involved
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(CCLR)

Agency Claim No. 

CCLR SUPPLEMENTARY DATA SHEET

Use this sheet to provide any additional information that might help locate those from whom the claim

might be collected and any assets that might be available to satisfy a judgment in favor of the United

States. Please indicate the number(s) of the block(s) on the CCLR that any additional data is intended to

supplement.
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(CCLR)

Agency Claim No. 

ACKNOWLEDGMENT FORM

-----------------------------------------------------------------------(FOLD HERE)---------------------------------------------------

DOJ/USAO ACKNOWLEDGMENT TO AGENCY

60. Debtor=s Full Name: 

61. Agency Claim No.: ______________________________

62. DOJ/USAO Number: ______________________________

63. Received at DOJ/USAO on: ______________________

64. Received at DOJ/USAO by: _____________________________________________

 (Print Name)

65. Questions?

Contact: __________________________________________________________

 (Print Name & Phone Number (Include Area Code) of DOJ/USAO Contact)

---------------------------------------(FOLD HERE)----------------------------------------

66.

67.

DOJ/USAO Return Address: 

Agency Address