THIS SPACE IS FOR COURT USE ONLY
Check box if you are aware that
anyone else has filed a proof of
claim relating to your claim. Attach
copy of statement giving
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.
Check this 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. Total Amount of Claim at Time Case Filed:
6. Unsecured Priority Claim.
Check this box if you have an unsecured priority claim
Amount entitled to priority $____________
Specify the priority of the claim:
Wages, salaries, or commissions (up to $4,650),* earned within 90 days before
filing of the bankruptcy petition or cessation of the debtor’s business, whichever
is earlier - 11 U.S.C. § 507(a)(3).
Contributions to an employee benefit plan - 11 U.S.C. § 507(a)(4).
Up to $2,100* of deposits toward purchase, lease, or rental of property or
services for personal, family, or household use - 11 U.S.C. § 507(a)(6).
Alimony, maintenance, or support owed to a spouse, former spouse, or child -
11 U.S.C. § 507(a)(7).
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)(____).
*Amounts are subject to adjustment on 4/1/04 and every 3 years thereafter with
respect to cases commenced on or after the date of adjustment.
Retiree benefits as defined in 11 U.S.C. § 1114(a)
Wages, salaries, and compensation (fill out below)
Your SS #: _______ ______ _______
Unpaid compensation for services performed
Account or other number by which creditor identifies debtor:
5. Secured Claim.
Check this box if your claim is secured by collateral (including a
right of setoff).
Brief Description of Collateral:
Value of Collateral: