UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF WASHINGTON PROOF OF CLAIM COMPLETE THIS FORM AND MAIL TO: PO BOX 2164, SPOKANE, WA 99210-2164 EDWA – LF 3001 10/05 Name of Debtor Case Number NOTE: 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 box if you are aware that anyone else has filed a proof of claim relating to your claim. Attach copy Name of Creditor (The person or other entity to whom the debtor owes money or of statement giving particulars. property): Check Box if you are filing this claim on behalf of the creditor who has not timely filed a proof of claim. Name and Address where notices should be sent: Check box if you have never received any notices from the bankruptcy court in this case. Check box if the address differs from the address on the envelope sent to you by the court. Name and address where payments should be sent (if different from above): Check here if this claim replaces amends a previously filed claim, dated: ____________ Telephone number: Last four digits of number by which creditor identifies debtor: 1. Total Amount of Claim At Case Filing: $______________ 2. Date debt was incurred: ___________________ Check box if claim is Unsecured and complete Section 6. Check box if some or all of claim is secured and complete Sections 4 and 6. Check box if some or all of claim is entitled to Priority and complete Sections 5 and 6. 3. If Court Judgment, date obtained: __________________ Check box if claim includes interest or other charges in addition to the principal amount of the claim. Attach itemized statement of all interest or additional charges. 4. Secured Claim: Check this box if your claim is secured by collateral (including a right of setoff). Brief Description of Collateral: Real Estate Motor Vehicle Other__________________ Value of Collateral: $_________________ Interest Rate ____________ Amount of arrearage and other charges at time case filed included in secured claim, if any $______________________ Total Amount of Secured Claim $_______________________ (may not exceed value of collateral) 6. SUMMARY OF PROOF OF CLAIM: TOTAL AMOUNT OF CLAIM $_____________________ (From Section 1) Secured $ _____________________ (From Section 5) Contributions to an employee benefit plan - 11 U.S.C. § 507(a)(5). Up to $2,225* of deposits toward purchase, lease, or rental of property or services for personal, family, or household use - 11 U.S.C. § 507(a)(7). Domestic support obligations under 11 U.S.C. § 507(a)(1)(A) or (a)(1)(B). Taxes or penalties owed to governmental units - 11 U.S.C. § 507(a)(8). Other - Specify applicable paragraph of 11 U.S.C. § 507(a)(____). $______________________ (From Section 4) Priority 5. Unsecured Priority Claim: Specify the priority of the claim: Wages, salaries, or commissions (up to $10,000),* 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) Amount Entitled to Priority: $_________________. Unsecured $_____________________ (Total Claim Less Secured Less Priority) *Amounts are subject to adjustment on 4/1/07 and every 3 years thereafter with respect to cases commenced on or after the date of adjustment. 7. Credits: The amount of all payments on this claim has been credited and deducted for the purpose of making this proof of claim. 8. Supporting Documents: Attach copies of supporting documents, such as promissory notes, purchase orders, invoices, itemized statements of running accounts, contracts, court judgments, mortgages, security agreements, and evidence of perfection of lien. FOR COURT USE ONLY DO NOT SEND ORIGINAL DOCUMENTS: If the documents are not available, explain. If the documents are voluminous, attach a summary. 9. Date-Stamped Copy: To receive an acknowledgment of the filing of your claim, enclose a stamped, self-addressed envelope and copy of this proof of claim or go to www.waeb.uscourts.gov. 10. Basis for Claim: Goods sold Services performed Money loaned Personal injury/wrongful death Taxes Other_________________ Date: Retiree benefits as defined in 11 USC § 1114(a) Wages, Salaries, and compensation (fill our below): Last four digits of SS# - __________ Unpaid compensation for services performed from ____________ to ____________. (date) (date) Sign and print the name and title, if any, of the creditor or other person authorized to file this claim (attach copy of power of attorney, if any): American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS FOR PROOF OF CLAIM FORM The instructions and definitions below are general explanations of the law. In particular types of cases or circumstances, such as bankruptcy cases that are not filed voluntarily by a debtor, there may be exceptions to these general rules. ------ DEFINITIONS -----Debtor Secured Claim Unsecured Claim The person, corporation, or other entity that has filed a bankruptcy case is called the debtor. A claim is a secured claim to the extent that the creditor has a lien on property of the debtor (collateral) that gives the creditor the right to be paid from that property before creditors who do not have liens on the property. If a claim is not secured claim it is an unsecured claim. A claim may be partly secured and partly unsecured if the property on which a creditor has a lien is not worth enough to pay the creditor in full. Creditor A creditor is any person, corporation, or other entity to whom the debtor owed a debt to the date that the bankruptcy case was filed. Proof of Claim A form telling the bankruptcy court how much the debtor owed a creditor at the time the bankruptcy case was filed (the amount of the creditor’s claim). This form must be filed with the clerk of the bankruptcy court where the bankruptcy case was filed. Examples of liens are a mortgage on real estate and a security interest in a car, truck boat, television set, or other item of property. A lien may have been obtained through a court proceeding before the bankruptcy case began; in some states a court judgment is a lien. In addition, to the extent a creditor also owes money to the debtor (has a right of setoff), the creditor’s claim may be a secured claim. (See also Unsecured Claim.) Unsecured Priority Claim Certain types of unsecured claims are given priority, so they are to be paid in bankruptcy cases before most other unsecured claims (if there is sufficient money or property available to pay these claims). The most common types of priority claims are listed on the proof of claim form. Unsecured claims that are not specifically given priority status by the bankruptcy laws are classified as Unsecured Nonpriority Claims. Items to be completed in Proof of Claim form (if not already filled in) 5.) Unsecured Priority Claim: Court , Name of Debtor, and Case Number: Fill in the name of the federal judicial district where the bankruptcy case was filed (for example, Central District of California), the name of the debtor in the bankruptcy case, and the bankruptcy case number. If you received a notice of the case from the court, all of this information is near the top of the notice. Information about Creditor: Complete the section giving the name, address, and telephone number of the creditor to whom the debtor owes money or property, and the debtor’s account number, if any. If anyone else has already filed a proof of claim relating to this debt, if you never received notices from the bankruptcy court about this case, if your address differs from that to which the court sent notice, or if this proof of claim replaces or changes a proff of claim that was already filed, check the appropriate box on the form. 1.) Total Amount of Claim at Time Case Filed: Fill in the total amount of the entire claim. If interest or other charges in addition to the principal amount of the claim are included, check the appropriate place on the form and attach an itemization of the interest and charges. 2.) Date Debt Incurred: Fill in the date when the debtor first owed the debt. 3.) Court Judgments: If you have a court judgment for this debt, state the date the court entered the judgment. 4.) Secured Claim: Check the appropriate place if the claim is a secured claim. You must state the value and type of property that is collateral for the claim, attach copies of the documentation of your lien, and state the amount past due on the claim as of the date the bankruptcy case was filed. A claim may be partly secured and partly unsecured. (See DEFINITIONS, above). Check the appropriate place if you have an unsecured priority claim, and state the amount entitled to priority. (See DEFINITIONS, above). A claim may be partly priority and partly nonpriority if, for example, the claim is for more than the amount given priority by the law. Check the appropriate place to specify the type of priority claim. 6.) Summary of Proof of Claim: Total amount of claim should match the total amount of claim from Section 1. The secured line should match the total amount of the Secured Claim from Section 4. The priority line should match the total amount of the Amount Entitled to Priority from Section 5. The unsecured amount should be the total amount of the claim less secured and priority from sections 4 and 5. If the claim is fully Unsecured, the total amount of the claim from Section 1 and total amount of claim in Section 6 should match this line. 7.) 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. 8.) Supporting Documents: You must attach to this proof of claim form copies of documents that show the debtor owes the debt claimed or, if the documents are too lengthy, a summary of those documents. If documents are not available, you must attach an explanation of why they are not available. 10.) 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 your last four digits of social security number and the dates of work for which you were not paid. American LegalNet, Inc. www.USCourtForms.com