UNITED STATES BANKRUPTCY COURT District of South Dakota Debtor’s name: PROOF OF CLAIM (Revised 12/07) Case number: Please see the Instructions that accompany this form for definitions and guidance on completing a proof of claim. Chapter: Creditor’s name: Last four digits of any number by which creditor identifies debtor: Send notices to (name and address): Check this box if you are aware that someone else has filed a proof of claim relating to your claim. Attach copy of statement giving particulars. Check this box if you are the debtor or trustee in this case. Phone number: ( 1. This form should not be used to make a claim for an administrative expense arising after the commencement of the case. A "request" for payment of an administrative expense may be filed pursuant to 11 U.S.C. § 503. Check this box if this claim is intended to replace a previously filed claim. Check this box if this claim is intended to amend a previously filed claim. Date of previously filed claim: ) Basis for claim (check all that apply and use "Other" to describe any claim not fitting within one of the listed categories): Goods sold Services performed Money loaned Personal injury/wrongful death Taxes Retiree benefits (per 11 U.S.C. § 1114(a)) Wages, salaries, or compensation, for services performed (insert dates): From: Other (describe): To: Last four digits of your SS #: 2. Date(s) debt incurred: 4. CLASSIFICATION OF CLAIM. Check the appropriate box(es) that best describes your claim. See reverse side for important explanations. 3. Date(s) of any judgment: UNSECURED NONPRIORITY CLAIM Check this box if: (a) there is no lien on property securing your claim; (b) your claim exceeds the value of the property securing it; (c) none or only part of your claim is entitled to priority. State the amount of any unsecured nonpriority claim in the space provided for "Unsecured" claims in section 5 below. SECURED CLAIM Check this box if your claim is secured by a lien on property (including a right of setoff). State the amount of any secured claim in the space provided for "Secured" claims in section 5 below. Check the appropriate box(es) if your claim is secured by: Real estate Motor vehicle(s) Other property (describe): Value of property: $_______________ Annual Interest Rate _______% UNSECURED PRIORITY CLAIM Check this box if you have an unsecured claim, all or part of which is entitled to priority. State the amount of any unsecured priority claim in the space provided for "Priority" claims in section 5 below. Check the appropriate box(es) if your claim is entitled to priority for: Domestic support obligations under 11 U.S.C. § 507(a)(1)(A) or (B). Wages, salaries, or commissions (up to $10,950*) earned within 180 days before filing of the bankruptcy petition or cessation of the debtor’s business, whichever is earlier - 11 U.S.C. § 507(a)(4). Contributions to an employee benefit plan - 11 U.S.C. § 507(a)(5). Deposits (up to $2,425*) toward purchase, lease, or rental of property or services for personal, family, or household use 11 U.S.C. § 507(a)(7). Taxes or penalties owed to governmental units - 11 U.S.C. § 507(a)(8). Other - 11 U.S.C. § 507(a)(____) (specify paragraph) * Amounts are subject to adjustment on 4/1/2010 and every three years thereafter with respect to cases filed on or after the date of the adjustment. Arrearage and other charges at the time the case was filed included in secured claim, if any: $ 5. TOTAL AMOUNT OF CLAIM AT TIME CASE FILED: $____________________+ a. Secured $____________________+ b. Unsecured $_____________________= c. Priority $____________________ TOTAL (a+b+c) 6. CREDITS: All payments on this claim have been credited for the purpose of making this claim. 7. THIS SPACE IS FOR COURT USE ONLY DOCUMENTS: Attach redacted copies of any documents that support the claim, such as promissory notes, purchase orders, invoices, itemized statements or running accounts, contracts, judgments, mortgages, and security agreements. Also attach redacted copies of documents providing evidence of the perfection of a security interest. You may also attach summaries. See definition of "redacted" on reverse side. 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 acknowledgment of the filing of your claim, enclose a stamped, self-addressed envelope and a copy of this proof of claim. Date: Signature: The person filing this claim must sign it. Sign and print name and title, if any, of the creditor or other person authorized to file this claim and state address and telephone number if different from the notice address above. Attach a copy of power of attorney, if any. American LegalNet, Inc. www.FormsWorkflow.com Penalty for presenting a fraudulent claim: Fine of up to $500,000 or imprisonment for up to five years, or both. 18 U.S.C. § § 152 and 3571. INSTRUCTIONS FOR PROOF OF CLAIM 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. If you have questions regarding these instructions and definitions, please consult an attorney. Neither the Clerk’s office nor the trustee (if one has been appointed) is permitted to give legal advice. Items to be completed on Proof of Claim form Court, Name of Debtor, and Case Number: Fill in the federal judicial district where the bankruptcy case was filed (for example, District of South Dakota), the bankruptcy debtor’s name, and the bankruptcy case number. If the creditor received a notice of the case from the bankruptcy court, all of this information is located at the top of the notice. Secured Claim: Check the appropriate box if you have a secured claim. (See DEFINITIONS, below). Check the appropriate box(es) to indicate the type(s) of property securing your claim. State the value of the property securing your claim, the annual interest rate, the amount of any arrearage (amount past due) and other charges as of the date the bankruptcy case was filed. Information about Creditor: Fill in the name, address, and telephone number of the creditor to whom the debtor owes money or property, and the last four digits of any number used by the creditor to identify the debtor. If anyone else has already filed a proof of claim relating to this debt, if you are the debtor or the trustee, or if this proof of claim replaces or amends a proof of claim that was previously filed, check the appropriate box on the form. A proof of claim replaces another proof of claim if it is intended to supersede a proof of claim filed by someone else on your behalf (such as the debtor, the trustee, a guarantor, or a co-debtor). A proof of claim amends another proof of claim if it is intended to correct or change a proof of claim you filed previously. The creditor has a continuing obligation to keep the court informed of its current address. See Federal Rule of Bankruptcy Procedure (Fed.R.Bankr.P.) 2002(g). 1. Basis for Claim: Check the type of debt for which the proof of claim is being filed. If the type of debt is not listed, check "Other" and briefly describe the type of debt. If you were an employee of the debtor, fill in the last four digits of your social security number and the dates of work for which you were not paid. 2. Date(s) Debt Incurred: Fill in the date(s) when the debt first was owed by the debtor. 3. Date(s) of any Judgment: If you have a court judgment for this debt, state the date(s) the court entered the judgment. 4. Classification of Claim Unsecured Nonpriority Claim: Check the appropriate box if you have an unsecured nonpriority claim, sometimes referred to as a general "unsecured claim." (See DEFINITIONS, below.) State the amount of any unsecured nonpriority claim in the space provided for "Unsecured" claims in section 5 of the form. If your claim is partly secured and partly unsecured (see "Secured Claim" below), or partly priority and partly nonpriority (see "Unsecured Priority Claim" below), state only the amount of your claim that is not secured and not entitled to priority in the space provided for "Unsecured" claims in section 5. State the amount of any secured claim in the space provided for "Secured" claims in section 5 of the form. If your claim is partly secured and partly unsecured (which it will be if it is for more than the value of the property securing your claim), state only the amount of your claim that is secured (the value of the property) in the space provided for "Secured" claims in section 5. Unsecured Priority Claim: Check the appropriate box if you have an unsecured priority claim. (See DEFINITIONS, below). Check the appropriate box(es) to indicate the paragraph of 11 U.S.C. § 507(a) under which you claim a priority. State the amount of any unsecured priority claim in the space provided for "Priority" claims in section 5 of the form. If your claim is partly priority and partly nonpriority (which it will be if it is for more than the amount given priority by law), state only the amount of your claim that is priority in the space provided for "Priority" claims in section 5. 5. Total Amount of Claim at Time Case Filed: Fill in the amount of your secured claim (if any), the amount of your unsecured claim (if any), the amount of your priority claim (if any), and the total amount of your claim on the date the bankruptcy case was filed. 6. Credits: By signing this proof of claim, you are stating under oath that in calculating the amount of your claim you have given the debtor credit for all payments received from the debtor. 7. Documents: Attach to this proof of claim redacted copies of documents that support the existence of the debt and any lien securing the debt. Also attach copies of documents that evidence the perfection of any security interest. You may also attach summaries. Do not send original documents, as attachments may be destroyed after scanning. Date and Signature: The person filing this proof of claim must sign and date it. Fed.R.Bankr.P. 9011. If the claim is filed electronically, Fed.R.Bankr.P. 5005(a)(2) authorizes courts to establish local rules specifying what constitutes a signature. Print the name and title, if any, of the creditor or other person authorized to file this claim. State the filer’s address and telephone number if it differs from the address given on the top of the form for purposes of receiving notices. Attach a complete copy of any power of attorney. Criminal penalties apply for making a false statement on a proof of claim. __________DEFINITIONS__________ Debtor A debtor is the person, corporation, or other entity that has filed a bankruptcy case. A lien may be voluntarily granted by a debtor or may be obtained through a court proceeding. In some states, a court judgment is a lien. A claim also may be secured if the creditor owes the debtor money (has a right to setoff). Creditor A creditor is the person, corporation, or other entity owed a debt by the debtor on the date of the bankruptcy filing. Unsecured Claim Claim A claim is the creditor’s right to receive payment on a debt that was owed by the debtor on the date of the bankruptcy filing. See 11 U.S.C. § 101(5). A claim may be secured or unsecured. An unsecured claim is one that does not meet the requirements of a secured claim. A claim may be partly unsecured if the amount of the claim exceeds the value of the property on which the creditor has a lien. Unsecured Priority Claim Proof of Claim A proof of claim is a form used by the creditor to indicate the amount of the debt owed by the debtor on the date of the bankruptcy filing. The creditor must file the form with the clerk of the same bankruptcy court in which the bankruptcy case was filed. Secured Claim A secured claim is one backed by a lien on property of the debtor. The claim is secured so long as the creditor has the right to be paid from the property prior to other creditors. The amount of the secured claim cannot exceed the value of the property. Any amount owed to the creditor in excess of the value of the property is an unsecured claim. Examples of liens on property include a mortgage on real estate or a security interest in a car. Priority claims are certain categories of unsecured claims that are paid from the available money or property in a bankruptcy case before other unsecured claims. Redacted A document has been redacted when the person filing it has masked, edited out, or otherwise deleted certain information. A creditor should redact and use only the last four digits of any social security, individual’s tax identification, or financial account number, all but the initials of a minor’s name and only the year of any person’s date of birth. ______INFORMATION______ Acknowledgment of Filing of Claim To receive acknowledgment of your filing, you may either enclose a stamped self-addressed envelope and a copy of this proof of claim or you may access the court’s PACER system (www.pacer.psc.uscourts.gov) for a small fee to view your filed proof of claim. _____________ _______ _ _ _ _ __ Offers to Purchase a Claim Certain entities are in the business of purchasing claims for an amount less than the face value of the claims. One or more of these entities may contact the creditor and offer to purchase the claim. Some of the written communications from these entities may easily be confused with official court documentation or communications from the debtor. These entities do not represent the bankruptcy court or the debtor. The creditor has no obligation to sell its claim. However, if the creditor decides to sell its claim, any transfer of such claim is subject to Fed.R.Bankr.P. 3001(e), any applicable provisions of the Bankruptcy Code (11 U.S.C. § 101 et seq.), and any applicable orders of the bankruptcy court. Evidence of Perfection Evidence of perfection may include a mortgage, lien, certificate of title, financing statement, or other document showing that the lien has been filed or recorded. American LegalNet, Inc. www.FormsWorkflow.com