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.
Name and Address of Creditor
(The person or other entity to whom the debtor owes money or property)
1. Basis for claim
Goods delivered within 20 days of the commencement of the case.
4. Brief description of claim
Attach support for your claim
Credits and setoffs
The amount of all payments on this claim has been credited and deducted for the purpose of making this claim.
In filing this claim, claimant has deducted all amounts that claimant owes to debtor.
Attachments / Supporting Documentation
Attach copies of supporting documents, such as purchase orders, invoices, itemized statements of
running accounts, receipts, bills of lading, or contracts. If the documents are not available, explain.
If the documents are voluminous, attach a summary. Attachments must be printed on 8-1/2" by 11" paper.
Attachments:
- Necessary documentation can be attached to the Claim form before the information for the form is submitted
- Attachments to the Claim form are required to be PDF files.
- Multiple attachments to the Claim form are permitted.
-
Do not upload a completed Claim form as an attachment to this filing.
Attaching a completed Claim will result in multiple versions of the form being filed (the electronically created claim form plus the claim attached). If filing an Amended Claim,
the attachment of the previously filed claim is allowed.
Click below to attach documentation
(see instructions)
.
ORDINARY COURSE CERTIFICATION:
By signing this claim request form, you are certifying that the goods for which payment is sought hereby,
were sold to the debtor in the ordinary course of the debtor's business as required by
11 U.S.C. § 503(b)(9).
The person completing this claim form must sign and date it. FRBP 9011(b).
If you file this claim electronically, FRBP 5005(a)(2) authorizes courts to establish local rules specifying what a signature is.
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.
Executed on date 4/15/2026
Print the name of the person who is completing and signing this claim:
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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.