United States Bankruptcy Court for the ________________District of__________________. Northern California NOTIFICATION STATEMENT TO: __________________________________ POSITION: POSITION: ________________________ ________________________ FROM:_______________________________ DATE:____________________ SIGNATURE OF PREPARER__________________________ PREPARER'S POSITION__________________________ 1. Basis for Notification and Possible Estate loss: a. Suspected violation of 18 U.S.C. Section: 152( ); 153( ); 154( ); 1341( ); 1342( ); 1343( ); 155( ); 1344( ) 156( ); 157( ); b. c. 2. Other suspected criminal violation _____________________________________ Possible Estate Loss $_______________________ Other___________________ Subject of Notification: a. b. c. d. e. f. ( ( ( ( ( ( ) Debtor (principal/responsible person) ) Trustee ) Professional (Specify Title)___________________________________________ ) Claimholder/Equity Security Holder ) Public Official ) Other_____________________________________________________________ 3. Background Information: a. Name of debtor's case:_______________________________________________ Case number/district:________________________________________________ Debtor's address: Telephone numbers:_________________________________________________ b. Case Chapter: Nature of Case: 7 ( ); 11 ( ); 12 ( ); Voluntary ( ); Involuntary ( ) 13 ( ); American LegalNet, Inc. www.USCourtForms.com PAGE 2 c. Debtor's attorney: Attorney's address: Telephone: Name of trustee: Appointment date: Trustee's address: Telephone: ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ d. e. Petition and schedules attached for lists of claimholders, debts, assets, exempt property, and other information: Yes ( ) No ( ) If chapter 7 case, Sec. 705 creditors' committee appointed: Yes ( ) No ( ) If yes, date of appointment: ________________________________________________ Name, address and telephone nos. of contact persons: f. g. If chapter 11 case, Sec. 1102 creditors' committee appointed: Yes ( ) No ( ) If yes, date of appointment: ________________________________________________ Name, address and telephone nos. of contact persons: h. Other information regarding the debtor's case: 4. Circumstances Relating to Suspected Violation of Chapter 9 of Title 18, United States Code, or other Laws of the United States Relating to the Debtor's Case a. Name of subject of notification: ____________________________________ Subject's address: ________________________________________________ Telephone numbers: ________________________________________________ American LegalNet, Inc. www.USCourtForms.com PAGE 3 Other identification information: b. Report all facts and circumstances of the case, the names of witnesses, and the offense or offenses believed to have been committed (provide as complete a description as possible) by: (1) Providing a full and complete account of the suspected violation. (2) Providing the names, addresses, and telephone numbers of persons with knowledge of and information relating to suspected offense. (3) Indicating, (based on available information) whether the suspected offense relates only to a single incident in a debtor's case or whether the suspected offense relates to multiple transactions/bankruptcies. (4) Indicating whether the subject of the notification has been the subject of a prior notification and, if so, relating the relevant circumstances surrounding the earlier notification. (5) Disclosing other pertinent information. A copy of the Notification has been sent to the Administrative Office of the United States Courts, Bankruptcy Judges Division, One Columbus Circle, N.E., Washington, D.C. 20544 American LegalNet, Inc. www.USCourtForms.com