FORM _B_1_0 (Official Form 10)(4/01) GANB
UNITED STATES BANKRUPTCY COURT for the Northern District of Georgia
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PROOF OF CLAIM
Name of Debtor:
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
Name of Creditor (The person or other entity to whom the debtor
owes money or property):
Name and Address where notices should be sent:
Check box if you are aware that
anyone else has filed a proof of
claim relating to your claim. Attach
copy of statement giving particulars.
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.
THIS SPACE IS FOR COURT USE ONLY
Account or other number by which creditor identifies debtor:
Check here if
a previously filed claim, dated ________
1. Basis for Claim
Personal injury/wrongful death
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
from ____________ to __________________
2. Date debt was incurred:
3. If court judgment, date obtained:
4. Total Amount of Claim at Time Case Filed:
If all or part of your claim is secured or entitled to priority, also complete Item 5 or 6 below.
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.
5. Secured Claim.
Check this box if your claim is secured by collateral
(including a right of setoff).