Form 4
(10/05)
United States Bankruptcy Court
_______________ District Of ______________
In re ___________________________________,
Case No. ___________________
Debtor
Chapter ____________
LIST OF CREDITORS HOLDING 20 LARGEST UNSECURED CLAIMS
Following is the list of the debtor’s creditors holding the 20 largest unsecured claims. The list is
prepared in accordance with Fed. R. Bankr. P. 1007(d) for filing in this chapter 11 [or chapter 9] case.
The list does not include (1) persons who come within the definition of “insider” set forth in 11 U.S.C.
§ 101, or (2) secured creditors unless the value of the collateral is such that the unsecured deficiency
places the creditor among the holders of the 20 largest unsecured claims. If a minor child is one of the
creditors holding the 20 largest unsecured claims, indicate that by stating “a minor child” and do not
disclose the child’s name. See 11 U.S.C. § 112; Fed. R. Bankr. P. 1007(m).
____________________________________________________________________________________
(1)
(2)
(3)
(4)
(5)
Name of creditor
Name, telephone number and
Nature of claim
Indicate if claim
Amount of claim
and complete
complete mailing address,
(trade debt,
is contingent,
[if secured also
mailing address
including zip code, of
bank loan, govern-
unliquidated,
state value of
including zip
employee, agent, or department
ment contract,
disputed or
security]
code
of creditor familiar with
etc.)
subject to setoff
claim who may be contacted
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Date: __________________________
_______________________________________
Debtor
[Declaration as in Form 2]