Laserfiche WebLink
'Please see Schedule 1 for a complete list of Debtor Entities <br />Official Form 410 <br />Proof of Claim <br />Read the instructions before filling out this form. This form is for making a claim for payment in a bankruptcy case. Do not use this form to <br />make a request for payment of an administrative expense. Make such a request according to 11 U.S.C. § 503. <br />Filers must leave out or redact information that is entitled to privacy on this form or on any attached documents. Attach redacted copies of any <br />documents that support the claim, such as promissory notes, purchase orders, invoices, itemized statements of running accounts, contracts, judgments, <br />mortgages, and security agreements. Do not send original documents; they may be destroyed after scanning. If the documents are not available, <br />explain in an attachment. <br />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. <br />Fill in all the information about the claim as of the date the case was filed. That date is on the notice of bankruptcy (Form 309) that you received <br />® Identify the Claim <br />1. Who is the current <br />creditor? <br />Colorado Division of Reclamation, Mining and Safety <br />Name of the current creditor (the person or entity to be paid for this claim) <br />Other names the creditor used with the debtor <br />2. Has this claim been <br />❑ No <br />acquired from <br />❑ Yes. From whom? <br />someone else? <br />3. Where should notices <br />Where should notices to the creditor be sent? <br />Where should payments to the creditor be sent? (if <br />and payments to the <br />different) <br />creditor be sent? <br />Colorado Division of Reclamation, Mining and Safety <br />Federal Rule of <br />1313 Sherman St. <br />Bankruptcy Procedure <br />#215 <br />Name <br />(FRBP) 2002(g) <br />Denver CO 80203 <br />Number Street <br />City State ZIP Code <br />Contact phone <br />Contact phone <br />Contact email <br />Contact email <br />4. Does this claim amend <br />❑ No <br />one alreadyfiled? <br />❑ Yes. Claim number on court claims registry (ifknown) <br />Filed on <br />MM / DD / YYYY <br />5. Do you know if anyone <br />❑ No <br />else has filed a proof <br />❑ Yes. Who made the eadierfiling? <br />of claim for this claim? <br />MML ID: 1823716 <br />Official Form 410 Proof of Claim page 1 <br />