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GUIDE61A.ARJ
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LHARC1.EXE
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4005.ARM
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1991-04-22
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/* 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.
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
in principal amount and $@433 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: ______________________
_______________________________________________________
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.