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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 <br /> i <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 <br /> _----•-^ - ..._._..�.--�........__-_ -..,,_, .... ,. a- ....-s: .T-..-..,...�,.,,. z,.s..��^�_�_.-..,., .:,.. �..w a-,r,::�>Yx-s•aav�.em.w*n-�a.,,.^.*a-.-T-+;muatw».-;.;.sf:-,sas'r+�:,;'. g <br />