Wages, salaries, bonuses, severance or commissions earned within 90
days of the assignment.
Other – Specify:
PROOF OF CLAIM
Assignment for the Benefit of Creditors
Name of Assignor:
Name of
Assignee:
Date of Assignment:
Filing Deadline:
Name of Creditor
(the person or entity to whom Assignor owes money or property):
Social Security # or Tax I.D. #:
Name and address where notices should be sent:
Email Address:
Address differs from the address on
the envelope sent to you on behalf of the
Assignee.
Claim amends a previously led claim.
If so, for such claim, indicate date
claim mailed:
Date debt was incurred
:
/ /
.
.
a. Amount of Secured Claim
+
b. Amount of Priority Claim
+
e. Total Amount of Claim
$
.
Month
Day
Year
1. Basis for Claim: (check all that apply)
Goods sold Services performed
Taxes Equipment
leased
Money Loaned Equity Interest
Other (Describe briey):
/ /
Month
Day
Year
If Court Judgment, date Judgment obtained:
$
$
Basis for perfection:
Basis for priority (describe):
Contributions to an employee benet plan.
Taxes or penalties owed to governmental units.
5. Equity Interest. Number of Shares Held: Basis/Value Per Share: Type:
6.
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 3 has been completed, attach copies of documents providing evidence of perfection
of a security interest. (See instruction #6) DO NOT SEND ORIGINAL DOCUMENTS. ATTACHED DOCUMENTS MAY BE DESTROYED AFTER SCANNING. If the
documents are not available, please explain:
7. 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.
/ /
Month
Day
Year
Preferred; attach documentation
Common
First Name, Last Name
Signature: _______________________________________________
Company:
Print Name:
.
c. Amount of Unsecured Claim $
+
d. Amount of Equity Claim $
=
Attach W-9
Telephone Number:
2. Provide amount of claim as of assignment date:
4. Additional Information on Priority Claim:
3. Additional information on Secured Claim:
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.
.
/ /
Month
Day
Year
ONE LETTER OR NUMBER PER BOX. TYPE, OR WRITE CLEARLY.
©2019
Title: __________________
September 29
, 2021
Fry's Electronics, Inc.
Frys (assignment for the benefit of creditors), LLC
April 2, 2021
click to sign
signature
click to edit
![]()
