Name of Creditor
(The person or other entity to whom the Debtor owes money or property)
Name and Address of Where Notices Should Be Sent
2. DATE GOODS WERE RECEIVED BY THE DEBTOR
Attach proof of delivery of such goods.
3. BRIEF DESCRIPTION OF CLAIM AND GOODS
Attach particular invoices for which any of the amounts described in this form was applied.
4. SUPPORTING DOCUMENTS
Attach copies of supporting documents, such as invoices, receipts, bills of lading and the like,
identifying the goods for which the claim is being asserted, which of the Debtors such goods
were shipped to, the date such goods were received by such Debtors, and the alleged value
of such goods. DO NOT SEND ORIGINAL DOCUMENTS. If the documents are not available, explain.
Any attachments must be 8-1/2” by 11”.
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(see instructions)
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5. 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.
6. ORDINARY COURSE CERTIFICATION
By signing this claim form, you are certifying that the goods, for which payment is sought hereby,
were sold to the Debtors in the ordinary course of the Debtors’ business and were received by
the Debtors within twenty (20) days prior to June 25, 2022, as required by 11 U.S.C. § 503(b)(9).
The person completing this claim form must sign and date it. FRBP 9011(b).
A person who files a fraudulent claim could be fined up to $500,000, imprisoned for up to 5 years, or both. 18 U.S.C. §§ 152, 157, and 3571.
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Verify debtor name prior to submitting claim to be filed.
Penalty for presenting fraudulent claim:
Fine of up to $500,000 or imprisonment for up to 5 years, or both.
18 U.S.C. §§ 152, 157, and 3571.