Fritz: All Fritz/All Fritz.zip/All Fritz/FILES/LEGAEGAL/LEGAL1.LZH/LHARC1.EXE/4000.BLD

Text File | 1993-01-06 | 6KB | 211 lines

#4000
@001 State the name of the claimant:
@400 Enter the District where case is pending:
@401 Enter the State where case is pending:
@402 State the case number:
@403 State the name of the debtor (bankrupt):
#4001/#4002/#4003/#4004 This claim is made by:
An individual, filing on his own behalf
An partnership, by a partner
A corporation by an employee/officer
Any of the above through an agent
#if#4001
@404 State the street address of claimant:
@405 Please enter the state of claimant's residence:
@406 Please state the zip code of claimant:
#endif
#if#4002
@407 State the name of partner making claim:
@408 Please state the street address of partner:
@409 Please enter the state of partner's residence:
@410 Please state the zip code of partner:
@411 Enter the name of the partnership:
@412 Please state names of other partners:
@413 Please state business address of partnership:
#endif
#if#4003
@490 Please state the name of corporate officer making claim:
@491 Please state the street address of officer:
@492 Please enter the state of officer's residence:
@493 Please state the zip code of corporate officer:
@494 Please state the title of corporate officer making claim:
@495 Please enter the state where corporation is organized:
#endif
#if#4004
@420 Please state the name of the agent making claim:
@421 Please state the address of agent:
@422 Enter the name of the claimant:
@423 Enter city, state of residence of the claimant:
#endif
#4005
!430 Please state the amount due:
@431/@431/@431 Please state the ground of liability:
Goods/services sold but not paid for
A promissory note
KEY IN VALUE
!432 Please state the principal amount of debt:
!433 Please state the amount of any additional charges:
@434/@434 Please state the reason for additional charges if any:
Interest
KEY IN VALUE
@435 Please state due date, if debt not yet due:
@436/@436 Please state date and court of judgment if any:
None
KEY IN VALUE
@437/@437 Please state if there is any counterclaim or setoff:
None
KEY IN VALUE
@438/@438 Security for the debt is:
None
KEY IN VALUE
@439/@439/@439/@439 State basis for priority:
None
Wages
Deposit made by a consumer
KEY IN VALUE
#end control section
#4000
/* Para. 4000- Bankruptcy proof of claim- long form */


                 UNITED STATES BANKRUPTCY COURT

@400 DISTRICT OF @401

                 CASE NO. @402


IN RE:




@403,




Debtor.


_____________________________________/
#4001
/* Para. 4001: Individual */


1. The undersigned, @001, who is the claimant herein, resides at
@404, @405 @406.
#4002
/* Para. 4002: Claimant partnership */


1. The undersigned, @407, who resides at @408, @409 @410, is a
member of @411, a partnership, composed of the undersigned and
@412, and doing business at @413, and is authorized to make this
proof of claim in behalf of the partnership.
#4003
/* Para. 4003: Corporation */

1. The undersigned, @490, who resides at @491, @492 @493, is the
@494 of @001, a corporation organized under the laws of @495 and
is authorized to make this proof of claim on behalf of the
corporation.
#4004
/* Para. 4004: Agent poc */


The undersigned, @420, who resides at @421, is the agent of @422,
of @423, and is authorized to make this proof of claim on behalf
of the claimant.
#4005
/* Para. 4005: Amount due */


2. The debtor was at the time of the filing of the petition
initiating this case, indebted [or liable] to the claimant, in
the sum of $@430 (!430 Dollars).



3. The consideration for this debt [or ground of liability] is as
follows:


@431


[If filed in a chapter 7 or 13 case] This claim consists of $
@432 (!432 dollars) in principal amount and $ @433 (!433 dollars)
in additional charges [or no additional charges]. [Itemize all
charges in addition to principal amount of debt state basis for
inclusion and computation, and set forth any other consideration
relevant to the legality of the charge.]


@434



4. [If the claim is founded on a writing] The writing on which is
claim is founded (or a duplicate thereof) is attached hereto [or
cannot be attached for the reason set forth in the statement
attached hereto.]



5. [If appropriate] This claim is founded on an open account,
which became [or will become due] on @435, as shown by the
itemized statement attached hereto. Unless it is attached hereto
or its absence is explained in an attached statement, no note or
other negotiable instrument has been received for the account or
any part of it.


6. No judgment has been rendered on the claim except: @436.


7. The amount of all payments on this claim has been credited and
deducted for the purpose of making this proof of claim.


8. This claim is not subject to any setoff or counterclaim
except: @437.


9. No security interest is held for this claim except @438.
[If security interest in property of the debtor is claimed] The
undersigned claims the security interest under the writing
referred to in paragraph 4 hereof [or under a separate writing
which (or a duplicate of which) is attached hereto, or under a
separate writing which cannot be attached hereto for the reason
set forth in the statement attached hereto]. Evidence of
perfection of such security interest is also attached hereto.


10. This claim is a general unsecured claim, except to the extent
that the security interest, if any, described in paragraph 9 is
sufficient to satisfy the claim. [If priority is claimed, state
the amount and basis thereof.] @439.



 Dated: ______________________










_______________________________________________________

@001


Penalty for presenting false claim: Fine of not more than $ 5,000
or imprisonment for not more than 5 years or both-- Title 18,
U.S.C. 152.