2016-01-12_GENERAL DOCUMENTS - P2012007

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12. Is all or part of the claim entitled to priority under 11 U.S.C. § 507(a)? A claim may be partly priority and partly nonpriority. For example, in some categones, the law limits the amount entitled to priority. No Yes. Check all that apply: Amount entitled to priority U Domestic support obligations (including alimony and child support) under 11 U.S.C. § 507(a)(1)(A) or (a)(1)(B). U Up to $2,775* of deposits toward purchase, lease, or rental of property or services for personal, family, or household use. 11 U.S.C. § 507(a)(7). $ U Wages, salaries, or commissions (up to $12,475*) earned within 180 days before the bankruptcy petition is filed or the debtor's business ends, whichever is earlier. $ 11 U.S.C. § 507(a)(4). U Taxes or penalties owed to govemmental units. 11 U.S.C. § 507(a)(8). $ U Contributions to an employee benefit plan. 11 U.S.C. § 507(a)(5). U Other. Specify subsection of 11 U.S.C. § 507(a)(_) that applies. $ * Amounts are subject to adjustment on 4/01/16 and every 3 years after that for cases begun on or after the date of adjustment Part 3: Sign Below The person completing this proof of claim 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. Check the appropriate box: ❑ I am the creditor. ❑ 1 am the creditor's attorney or authorized agent. ❑ I am the trustee, or the debtor, or their authorized agent. Bankruptcy Rule 3004. ❑ I am a guarantor, surety, endorser, or other codebtor. Bankruptcy Rule 3005. I understand that an authorized signature on this Proof of Claim serves as an acknowledgment that when calculating the amount of the claim, the creditor gave the debtor credit for any payments received toward the debt. I have examined the information in this Proof of Claim and have a reasonable belief that the information is true and correct. I declare under penalty of perjury that the foregoing is true and correct. Executed on date MM / DD / YYYY 0 Signature Print the name of the person who is completing and signing this claim: Name Title Company Address First name Middle name Last name Identify the corporate servicer as the company if the authorized agent is a servicer. Number Street City State ZIP Code Contact phone Email Official Form 410 Proof of Claim page 3