2016-06-28_GENERAL DOCUMENTS - C1994082

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12. Is all or part of the claim ❑ No entitled to priority under 11 U.S.C. § 507(a)? ❑ Yes. Check all that apply Amount entitled to priority A claim may be partly ❑ Domestic support obligations (including alimony and child support) under priority and partly 11 U S C § 507(a)(1)(A) or (a)(1)(B) nonprronty For example, in some categories, the ❑ Up to $2,850' of deposits toward purchase, lease, or rental of property or law limits the amount services for personal, family, or household use 11 U.S.0 § 507(a)(7). entitled to priority ❑ Wages, salaries, or commissions (up to $12,850") 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) ❑ Taxes or penalties owed to governmental units 11 U.S.0 § 507(a)(8). $ ❑ Contributions to an employee benefit plan. 11 U.S C § 507(a)(5) $ ❑ Other. Specify subsection of 11 U S.0 § 507(a)(_) that applies $ Amounts are subject to adjustment on 4/01/19 and every 3 years after that for cases begun on or after the date of adjustment 13 Is all or part of the claim ❑ No pursuant to 11 U.S.C. § 503(b)(9)? ❑ Yes Indicate the amount of your claim arising from the value of any goods received by the debtor within 20 days before the date of commencement of the above case, in which the goods have been sold to the Debtor in the ordinary course of such Debtor's business Attach documentation supporting such claim. 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 ❑ I 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 acknowledgement 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 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 Signature Print the name of the person who is completing and signing this claim: Name Title Company Address Contact phone 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 Country Email Official Form 410 Proof of Claim II11 II III II 111 IIIII III II II11 II 1111 11 11111111 II 111 III page 3 1642644160620183342010891