Case 1:20-bk-12043 Doc 621 Filed 02/24/21 Entered 02/24/21 14:52:42 Desc Main
<br /> Document Page 35 of 40
<br /> Untied States Bankruptcy Court far Ohio-southern District
<br /> Hopedale Mininit LLC Claims Processing Center
<br /> c/o Epiq Corporate Restructuring,LLC Your Mad ID is as follows 1 79564016
<br /> P.O.Soa4421
<br /> Beaverton,OR 97076-4411
<br /> Name of Debtor: CAM MINING LLC i
<br /> Case Number: 20.12069(GRH)
<br /> i
<br /> � hlllNl�fli i� fll�(NINl�I I lllfl�l �l ----- For Court -- --_ ---
<br /> I AR(23)MAIUD-000l M64016"' I
<br /> B'LLIE COLS
<br /> C:IO SAMUEL HANNA i
<br /> I OABOX
<br /> X 2311 WV 2s32g Your claim is scheduled by the Debtor as.
<br /> CH
<br /> UNSECURED I
<br /> UNLIOUIDATED DISPUTED
<br /> CONTINGENT UNDETERMINED
<br /> Proof of Claim (Official Form 420) •---_---— .._ ------------_-- 04119
<br /> Read the instructions before filling out this form.This forms for m.;king a claim for payment in a bankruptcy case. With the exception of claims
<br /> i
<br /> under 503(b)(9),do not use this form to make a request for payment of an administrative eaprnse.Make such a request according to 11 U.S.C.§503.
<br /> filers must kavt out of redact inforrnaton that is entitied to privacy an this form or on any attached documents Attach redactedcopies of any
<br /> documents that support the claim,such_s promissory rotes,purchase orders,invoices,itemited statements of running accounts.ca,tracts,judgments
<br /> nnonsageS,and securi!y agreements Do not send original documents;they may be destroyed after scannm,g If the docurr.;rots are not available,
<br /> explain in an attachment. !
<br /> A person who files a frauduleri claim could 5c lined up to S5C3,000.imprisoned for up l0$years,or tiotI, )S U 5 C.§4 15:,157,and 3571 7
<br /> Fill in all the information about the claim as of the date the use 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 creditw? j
<br /> l Name of the current credno,(the person a,entity to be paid for this cii.m) Kenneth Cole
<br /> l Other names the creditor used with the debtor _
<br /> Has this claim been supiired from someone else? 0 No 0 yes From whom?
<br /> 3. M we should notices ant payments to the creditor be sent?Federal Rork of Bankruptcy Ptc--dure fF RUP)10021ii a•Does this claim amend one already filed) I 1
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<br /> Where dsotdd notices to the uedltor be tent? Whom should payments lathe creditor be sent? I u No i
<br /> (dd,fleient) ( f t l
<br /> Pierson Legal Services Kenneth Cole C/O Samuel 1lanns I r� Yes Clain number on court i f
<br /> _ _.-.___�..--- - --�------ - -- - - -_-- +clawms legate,bl inoNn)
<br /> Name - Name
<br /> P.O.Box 2291 P.U.Box 2311 —� Filed on r
<br /> mryt !0D nyr
<br /> Number suh c — Number Street
<br /> Charleston, WV 25328 Charleston, WV 25328 S.Do you know N anyone else has Rkd a
<br /> - -- --- proof of claim lot this dalm?
<br /> i - -- Srale- -----_-ZIF Code city Stae LF code r I
<br /> _ 0No
<br /> CWdry pf intemarwnaq'_ Country Ire international),
<br /> 304-925-2400 -�-— 304-342-2137 — ~ U yes who made me Bart er ra rig?
<br /> Contact phone _ Contact phone
<br /> lconlaclenij,l cone,em ul. _Shanna@&hannalawwv.com
<br /> Give Information About the Claim as of the Date the Case Was Piled �
<br /> 6. Do you have any number you vie to ? I.Now much Is the daim7 I g.What h the basis of the claim?
<br /> identify the debtor?
<br /> %No I 500.000.00 Laamples Goods sold,money loaned,tease,services performed,
<br /> i S personal injury or wrongful death.or credit card Attacr redacteo
<br /> �] yrs copies of any documents supporting the claim required by Bankrupt Y '
<br /> Does this amount Include Interest or other j f
<br /> car 4 digits sit the debtor's accou�d or Rey charges? Rule 3001(c). Limn disclosing information that s entitled to privacy. - t
<br /> number you ust to identify the debtor such as health care information ?
<br /> O No t
<br /> t
<br /> '"- -- -- ---- I tj, ties totach re-sl firs See Attached Civil Complaint
<br /> rapenses,or other cra rges regmrrd by I
<br /> Bankruptcy Rule 300:(c)(2)IA)
<br /> t
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