LBF #B10A (12/1/18) UNITED STATES BANKRUPTCY COURT District of Oregon Proof of Non - Professional Administrative Expense Name of Debtor(s): Case Number: Name of Claimant: Check this box to indicate that this proof of expense amends a previously filed proof of expense. Filed on: Check this box if you are aware that anyone else has filed a proof of expense relating to the claimed expense. Attach a statement giving particulars. Name and address where notices should be sent: Telephone number: Name and address where payment should be sent (if different from above): Telephone number: 1. Amount of Administrative Expense Claimed: $ Check this box if expense claimed includes interest or other charges in addition to the principal amount of the expense. Attach itemized statement of interest or charges. 2. Basis for Expense Claimed: Actual and necessary costs of preserving the estate (11 U.S.C. 247 503(b)(1)(A)) Taxes (11 U.S.C. 247 503(b)(1)(B)) Non-professional actual and necessary expenses incurred by creditor (11 U.S.C. 247 503(b)(3)) Compensation for services rendered by an indenture trustee (11 U.S.C. 247503(b)(5)) Fees and mileage per Chapter 119 of Title 28, U.S. Code (11 U.S.C. 247 503(b)(6)) Claim for rejection of non-residential real property lease following assumption under 11 U.S.C. 365 (11 U.S.C. 247 503(b)(7)) Actual and necessary costs and expenses of closing a health care business (11 U.S.C. 247 503(b)(8)) Goods provided to debtor within 20 days before the commencement of the case (11 U.S.C. 247 503(b)(9)) 3. Date(s) Expense Incurred: 4. Last 4 digits of any number by which claimant identifies debtor: 5. Credits: The amount of all payments made on this claimed expense has been credited for the purpose of making this proof of expense. THIS SPACE IS FOR COURT USE ONLY 6. Documents : Attach redacted copies of any documents that support the expense claimed, such as promissory notes, purchase orders, invoices, itemized statements or running accounts, contracts, and judgments. You may also attach a summary. (See instruction 6 and definition of "redacted.) Do not send original documents. If the documents are not available, please explain: American LegalNet, Inc. www.FormsWorkFlow.com LBF #B10A (12/1/18) Sign and print the name and title, if any, of the claimant or other person authorized to file this proof of expense. Provide address and telephone number if different from the notice address above. Attach copy of power of attorney if applicable. Date: Signature: Printed name/title: Address if applicable: Penalty for presenting fraudulent claim: Fine of up to $500,000 or imprisonment for up to 5 years, or both 226 18 U.S.C. 247247 152 and 3571. Filing of Proof of Expense File with the clerk at 1050 SW 6th Ave. #700, Portland OR 97204 or 405 E 8th Ave. #2600, Eugene OR 97204. To receive acknowledgment of your filing, you may either enclose a stamped self-addressed envelope and a copy of this proof of expense if it is filed on paper, or you may access the court's PACER system at https://ecf.orb.uscourts.gov to view your filed proof of expense. Visit the PACER Service Center at https://www.pacer.gov for more information. DEFINITIONS Administrative Expense An administrative expense is a type of expense set forth in 11 U.S.C. 247 503(b). Major examples of administrative expenses include the actual and necessary costs of preserving the estate, certain taxes, fees and mileage, claims for rejection of non-residential real property lease following assumption under 11 U.S.C. 247 365, actual and necessary costs and expenses of closing a health care business, and goods provided to debtor within 20 days before the commencement of the case. Trustee and professional compensation under 11 U.S.C. 247 503(b)(2) and (4) are administrative expenses but are not compensable using this form. See Local Bankruptcy Rule 2016-1 for information regarding trustee and professional compensation. Debtor A debtor is the person, corporation, or other entity that has filed a bankruptcy case. Claimant A claimant is a person, corporation, or other entity seeking payment of an administrative expense under 11 U.S.C. 247 503. Proof of Non-Professional Administrative Expense A proof of non-professional administrative expense is a form used by the claimant to indicate the amount of an administrative expense as of the date of the filing of the form. The claimant must file the form with the clerk of the same bankruptcy court in which the bankruptcy case was filed. Redacted A document has been redacted when the person filing it has masked, edited out, or otherwise deleted certain information. A filed document should display only the last four digits of any Social Security, individual222s taxpayer identification, or financial account number, only the initials of a minor's name, and only the year of any person's date of birth. American LegalNet, Inc. www.FormsWorkFlow.com LBF #B10A (12/1/18) INSTRUCTIONS FOR PROOF OF NON-PROFESSIONAL ADMINISTRATIVE EXPENSE FORM The instructions and definitions below are general explanations of the law. In certain circumstances, such as bankruptcy cases not filed voluntarily by the debtor, there may be exceptions to these general rules. Name of Debtor and Case Number: Fill in the bankruptcy debtor's name, and the bankruptcy case number. If the claimant received a notice of the case from the bankruptcy court, this information is located at the top of that notice. Claimant's Name and Address: Fill in the name of the person or entity asserting the claimed administrative expense and the name and address of the person who should receive notices issued during the bankruptcy case. A separate space is provided for the payment address if it differs from the notice address. The claimant has a continuing obligation to keep the court informed of its current address. See LBR 2002-1(g). 1. Amount of Expense Claimed: State the total amount owed to the claimant as of the date of the filing of this document. Check the box if interest or other charges are included in the claimed expense. 2. Basis for Claim: State the applicable subsection of 11 U.S.C. 247 503 which supports the claimed administrative expense. If the claim is based on the delivery of health care goods or services, limit the disclosure of the goods or services to avoid embarrassment or the disclosure of confidential health care information. You may be required to provide additional disclosure if the trustee or another party in interest files an objection to the claimed administrative expense. 3. Date Expense Incurred: State the date when the claimed expense was incurred. 4. Last Four Digits of Any Number by Which Creditor Identifies Debtor: State the last four digits of the debtor's account or other number used by the claimant to identify the debtor. 5. Credits: An authorized signature on this proof of expense serves as an acknowledgment that when calculating the amount of the expense claimed, the claimant gave the debtor credit for any payments received toward the expense. 6. Documents: Attach redacted copies supporting the claimed expense to this proof of expense. You may also attach a summary. If the claim is based on the delivery of health care goods or services, see instruction 2. Do not send original documents, as attachments may be destroyed after scanning. Date and Signature: The person filing this proof of expense must sign and date it. American LegalNet, Inc. www.FormsWorkFlow.com