Assignment for the Benefit of Creditors of:
Name of Assignor: __________________________________
PROOF OF CLAIM
OFFICE USE ONLY
Name of Assignee: _____________ (assignment for the benefit of creditors), LLC
Date of Assignment: ________________________________
Additional Information: (check box)
Name of Creditor (the person or entity to whom Assignor owes money or
property):
Social Security or Tax I.D. #: __________________
Address differs from the address on the
envelope sent to you on behalf of the Assignee.
Claim amends a previously filed claim. If
so, for such claim, indicate:
Name and address where notices should be sent:
Telephone Number: ( ) ________ - ____________
Contact name: ________________________________
Email Address: ________________________________
- Date claim mailed: ____________
Payment should be sent to different address.
Indicate name and address:
__________________________________
__________________________________
CLAIM NO.: ______
1. Amount of Claim (as of assignment date): $_______________
Check box if all or part of claim is secured and complete item 4.
Check box if all or part of claim is entitled to priority and complete item 5.
Check box if all or part of amount is for equity interest and complete item 6.
Check box if claim includes interest or other charges in addition to the
Principle amount of the claim and state amount: $_____________
In addition, attach statement that itemizes interest or charges.
2. Basis for Claim: (check one)
Goods sold Services performed
Money loaned Equipment leased
Taxes Equity Interest
Other (Describe briefly): ______________________________________
___________________________________________________________
Date debt was incurred: ________________________________
If Court Judgment, date Judgment obtained: _________________________
3. Last four digits of any number by which creditor identifies assignor: 3a. Assignor may have scheduled account as:
__ __ __ __ _____________________________________
4. Secured Claim:
Check the appropriate box if the claim is secured by a lien on property or a right of
setoff, attach all documents that support the contention that the claim is secured.
Nature of property or right to setoff:
Real Estate Personal Property Motor Vehicle Other
Describe: ______________________________________________________
Value of Property: $______________________
Annual Interest Rate: _____ %
Fixed Variable (when assignment started)
Amount of arrearage and other charges as of the time the of assignment,
included in secured claim, if any: $______________________
Basis for perfection: ______________________________________________
________________________________________________________________
Amount of Secured Claim: $______________________
Amount Unsecured: $______________________
5. Priority Claim: Amount of Claim entitled to priority (See instruction #5) and the basis on which such priority is claimed. If any part of the claim falls into one of the
following categories, check the box specifying the priority and state the amount.
Wages, salaries, bonuses, severance or commissions earned within 90 days
prior to the assignment.
Contributions to an employee benefit plan.
Taxes or penalties owed to governmental units.
Other – Specify: _______________________________________________
Amount entitled to priority: $__________________
Basis for priority (describe): _______________________________________
6. Equity Interest: Number of Shares Held: _________ Basis/Value Per Share: $ ________ Type: Common Preferred; attach documentation
7. Documents: Attach copies of any documents that support the claim, such as promissory notes, purchase orders, invoices, itemized statements of running accounts,
contracts, judgments, mortgages, and security agreements. If the claim is secured, and box 4 has been completed, attach copies of documents providing evidence of
perfection of a security interest. (See instruction #7) 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 acknowledgement of the filing of your claim, enclose a stamped, self-addressed envelope and copy of this proof of claim.
9. Signature: Check the appropriate box: ❐ I am the creditor. ❐I am the creditor’s authorized agent. ❐I am a guarantor, surety, endorser, or other co-debtor.
BY MY SIGNATURE BELOW, I DECLARE UNDER PENALTY OF PERJURY, UNDER THE LAWS OF THE STATE OF CALIFORNIA, THAT THE
INFORMATION PROVIDED HEREIN AND ATTACHED HERETO IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
Print Name: ____________________________________________ Title: __________________________ Company: _________________________________
Signature: ______________________________________________ Dated: _____________________
Telephone Number: ( ) ____ - _______ Email Address: _________________________________
12/01/2011
