Proof Of Claim Form - State Of California

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THIS SPACE IS FOR

OFFICE USE ONLY

Assignment for the Benefit of Creditors of:

PROOF OF CLAIM

Name of Assignor: __________________________________

DATE RECEIVED:

Name of Assignee: _____________ (assignment for the benefit of creditors), LLC

Additional Information: (check box)

Date of Assignment: ________________________________

Name of Creditor (the person or entity to whom Assignor owes money or



Address differs from the address on the

property):

envelope sent to you on behalf of the Assignee.



Claim amends a previously filed claim. If

Social Security or Tax I.D. #: __________________

so, for such claim, indicate:

Claim number: ________

Name and address where notices should be sent:

Date claim mailed: ____________



Payment should be sent to different address.

CLAIM NO.:

______

Indicate name and address:

__________________________________

Telephone Number: (

) ________ - ____________

__________________________________

Contact name: ________________________________

Email Address: ________________________________

1. Amount of Claim (as of assignment date): $_______________

2. Basis for Claim: (check one)



Check box if all or part of claim is secured and complete item 4.

Goods sold

Services performed



Check box if all or part of claim is entitled to priority and complete item 5.

Money loaned

Equipment leased



Check box if all or part of amount is for equity interest and complete item 6.

Taxes

Equity Interest



Check box if claim includes interest or other charges in addition to the

Other (Describe briefly): ______________________________________

Principle amount of the claim and state amount: $_____________

___________________________________________________________

In addition, attach statement that itemizes interest or charges.

Date debt was incurred: ________________________________

If Court Judgment, date Judgment obtained: _________________________

3. Last four digits of any number by which creditor identifies assignor:

3a. Assignor may have scheduled account as:

__ __ __ __

_____________________________________

4. Secured Claim:

Check the appropriate box if the claim is secured by a lien on property or a right of

Amount of arrearage and other charges as of the time the of assignment,

setoff, attach all documents that support the contention that the claim is secured.

included in secured claim, if any: $______________________

Nature of property or right to setoff:



Basis for perfection: ______________________________________________

Real Estate

Personal Property

Motor Vehicle

Other

________________________________________________________________

Describe: ______________________________________________________

Amount of Secured Claim: $______________________

Value of Property: $______________________



Amount Unsecured:

$______________________

Annual Interest Rate: _____ %

Fixed

Variable (when assignment started)

5. Priority Claim: Amount of Claim entitled to priority (See instruction #5) and the basis on which such priority is claimed. If any part of the claim falls into one of the

following categories, check the box specifying the priority and state the amount.



Wages, salaries, bonuses, severance or commissions earned within 90 days

Other – Specify: _______________________________________________

prior to the assignment.

Amount entitled to priority: $__________________



Contributions to an employee benefit plan.

Basis for priority (describe): _______________________________________



Taxes or penalties owed to governmental units.



6. Equity Interest:

Number of Shares Held: _________

Basis/Value Per Share: $ ________

Type:

Common

Preferred; attach documentation

7. Documents: Attach 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. If the claim is secured, and box 4 has been completed, attach copies of documents providing evidence of

perfection of a security interest. (See instruction #7) DO NOT SEND ORIGINAL DOCUMENTS. ATTACHED DOCUMENTS MAY BE DESTROYED AFTER

SCANNING. If the documents are not available, please explain: _______________________________________________________________________________

8. DATE-STAMPED COPY: To receive an acknowledgement of the filing of your claim, enclose a stamped, self-addressed envelope and copy of this proof of claim.

❐I am the creditor’s authorized agent.

❐I am a guarantor, surety, endorser, or other co-debtor.

❐ I am the creditor.

9. Signature:

Check the appropriate box:

BY MY SIGNATURE BELOW, I DECLARE UNDER PENALTY OF PERJURY, UNDER THE LAWS OF THE STATE OF CALIFORNIA, THAT THE

INFORMATION PROVIDED HEREIN AND ATTACHED HERETO IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

Print Name: ____________________________________________

Title: __________________________

Company: _________________________________

Signature: ______________________________________________ Dated: _____________________

Telephone Number: (