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12.Is all or part of the claim ❑ No <br /> entitled to priority under <br /> 11 U.S.C.§507(a)? ,---,Yes Check one Amount entitled to priority <br /> A claim may be partly U Domestic support obligations(including alimony and child support)under <br /> priority and partly 11 U S.0 §507(a)(1)(A)or(a)(1)(B) $-- — <br /> nonpriority For example, <br /> in some categories,the ❑ Up to$2,850*of deposits toward purchase,lease,or rental of property or services for <br /> law limits the amount personal,family,or household use 11 U.S.0 §507(a)(7). $— <br /> entitled to pnority <br /> ❑ Wages,salaries,or commissions(up to$12,8501 earned within 180 days before the <br /> bankruptcy petition is tiled or the debtor's business ends,whichever is earlier $ _-- <br /> 11 U S.0 §507(a)(4) <br /> i <br /> U Taxes or penalties owed to governmental units.11 U.S C.§507(a)(8) $_---_-- <br /> ❑ Contnbutions to an employee benefit plan 11 U.S C §507(a)(5). $ _ <br /> U Other.Specify subsection of 11 U.S.0 §507(a)(_)that applies $ <br /> Amounts are subject to adjustment on 4/01119 and every 3 years after that for cases begun on or after the date of adjustment. <br /> Part 3: Sign Below <br /> The person completing Check the appropriate box' <br /> this proof of claim must <br /> sign and date it. ❑ I am the creditor. <br /> FRBP 9011(b). ❑ I am the creditor's attorney or authorized agent <br /> If you file this claim ❑ I am the trustee,or the debtor,or their authorized agent.Bankruptcy Rule 3004 <br /> electronically,FRBP <br /> 5005(a)(2)authonzes courts CII am a guarantor,surety,endorser,or other codebtor.Bankruptcy Rule 3005 <br /> to establish local rules <br /> specifying what a signature I understand that an authorized signature on this Proof of Claim serves as an acknowledgment that when calculating the <br /> is <br /> amount of the claim,the creditor gave the debtor credit for any payments received toward the debt. <br /> A person who files a <br /> fraudulent claim could be I have examined the information in this Proof of Claim and have a reasonable belief that the information is true <br /> fined up to$500,000, and correct <br /> Imprisoned for up to 5 <br /> years,or both. I declare under penalty of perjury that the foregoing is true and correct <br /> 18 U.S.C.§§152,157,and <br /> 3571. <br /> Executed on date <br /> MM/ DO / YYYY <br /> Signature <br /> Print the name of the person who is completing and signing this claim: <br /> Name <br /> First name Middle name Last name <br /> Title <br /> Company <br /> Identify the corporate servicer as the company if the authorized agent is a servicer. <br /> Address <br /> Number Street <br /> City State ZIP Code <br /> Contact phone Email <br /> Official Form 410 Proof of Claim page 3 <br /> 046762 72304046808035 <br />