2021-03-29_GENERAL DOCUMENTS - C1980004

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Case 1:20-bk-12043 Doc 621 Filed 02/24/21 Entered 02/24/21 14:52:42 Desc Main Document Page 36 of 40 9.Is all or part of the claim secured? _ — -- 10. is thh claim baked on a tease? 31.k[his claim subject to a rkghI or setoff? - i )(No No Y No yes The claim is secured by a ken on property. ❑yes.Amount rsecewry to cure (]yes Identity the proprrty l kkurr of property: any default as of the date of petition l)Mal estate 1!the ctaKn is secured tr the debtoi s pnntipil S — --— 1 residence,file a Mortgopr Proof of oolm Atrochment(official form 12.is allot part of the claim entitled to priority A claim may be partly prxarty and 1 a 1t7•A)with this Woof of Cssirn under 11 U.S.0 9 SO7(a)? partly nonprnorny for runpir,rr ! I some categories,the law limits it* it ❑ Motor vehicle Q No amount entitled to pnonty ! O Other Describe Q YK- check ono Amount entitled to MMrN1r Basis for Perfection.. _ Q Domestic support obNgatlons(including air"and S j child support)under 11 U$C.4 5O7(a)(10)or(AWNS) ' i I t Altach redacted copies of documents,it any.that show evidence of D up to S3.:,2S•of deposits toward purchase,lease,or S 1 I iperfection ofsecur^y interest(for example,a mortgage,lien, rental ofpMertyOr services for personal,flmh,of ' {{{ Indicate of title,finariongstatement.or othe•document that household use 11 US.C.11 SO71a)(1). shows the ken has been fried or recotdrd) Q Wages,salaries,or commissions(up to 51:,65O.1 S r Value Of flfmprrty: S ; earned within IPO days befrre the bankrupts r petrrron is f{ tiled or the debtors business ends,whichever-5 earlier i l Amount of tht claim that is secured: $ 13 U 5-C 4 w7144)• Amount of tht Balm that is unsecured; Cl lakes of penalties owed to gaverhmer tal units S (The sum of the secured and unsecured amounts should match 11, 11 uS,C.4 SO7ia)(S6 r amount in fine 7 1 j l�Conlnbuirons to an emplayer benefit plan I I U S C 4 SO7(a)(S) 1 Amount nota:ssery to Care any I S i default as of flee date ottfupethlon: S Q Other Spccoy.u'-secion of 11 U 5 C ¢507(al(_I that applies ! Annual hrtetest Rate le hen case was hiedi _ % , Amounts;rt subject to adistment on 4101122 and every 3 years_:Orr that tar rases Leg", or ...i fluid U VariableI aftr the date of adjustment ) 1 13,Does thk claim qualify as an Adminutniive Eapasse under it U.S,C.Ir 50411bN9)? I 1 No + ❑res,Amount that qualifies"an Administrative Expense under 11 U.S,C_ff SONb)19) S54M Below ' t. i The person completing Check the approprrote box Olds prswf of claim must t tam the creditor 3 s{�s a m Oats IL FKSP 9O11(b). a7 I am Gee creditor s attorney or authorised agent Q I am the trustee,or the debtor,or their authorized agent Sankruptey pule KIN if you file this claim !! electronically,cggP 3 I am i gwrania,surety,endorser,orother co-debtor Bankruptcy Rule 3O05 5OO5(a)(1)authorizes 1 understand that an euthcrued signature on thri Prop/o/Csuim serves as an acknowledgment that when nkulati sg the amount of the claim, counsto establish lout the creditor gave the debtor credit for any payments received toward the debt- tpleyfyingwhat a sign (have examined the information h y ormation in this r signature is oil/o;Clomr and have a reasonable bike}that ant rformaton is true and correct ! 1 declare under penally of perjury that the foregoing is t erect. A prraon letup flks a i77UdVilnt claim could be trod up to SS00,O0O, Executed on date imprisoned for up to S MM J DD 1 YYTY a u e p yrom or bMq.is U.S.r- 01s2,157,and 3571. Print the nam Me per who k compie rid stgnitig this dak- Name �A ><d/ ( U�� iT of name Middle nsa Last name t Title f I Company Ill Lily the corporate serw'cer a the company I the authorized agent,s a servitorAodress j ber Street i t j & i _ ------ -- ---- � z- City St le ZIP Code / 1 t Contact Pnont 00_y V �� ---- Finait��S!1 c11�1G�V !I 1tN_�r/CS=