GENERAL37907

• Permit No: M1980020
• IBM Index Class Name: General Documents
• Doc Name: PROOF OF CLAIM
• Media Type: D
• Archive: No

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United States Bankruptcy Court III
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PROOF OF CLAIM
Colorado (Denver) II IIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIII
In re (NluTre W Debtor) Case Number 96-t 2009-r)b
Braley Sand And Grawf, Inc. ,uyt~,
Cred.ld: 2497680
NOTE: This loan should rot De used to make a C4im for en administrative expense arising alter the commencement r#
the case. A ryequesC for payment M en administrative expense may De filed pursuant 1011 U.S.C. { 5p8.
Name OI CfedROr ^ Check Dax a you ere aware that
(The person andrarerayro Mrom O`re detex owes moneyaprupcvfy) anyone else has filed eDroold
('.Olerad0 Slate TrealYror claim relating t0 your claim. Attach
Name afld Address Where N01108s $hOUltl be $eM copy of statement giving particulars.
Colorado State Troasurer ^ Check Dox a you have never received
Denver, CO any notices from the bankruptcy
court in this case.
^ Check Oox it the address diners
from the atltlress on the envelope THIS SPACE IS FOR
Telephone No. sent to you by the court. COURT USE ONLY
ACCOUM OR OTHER NUMBER BY Vi1sCH CREDITOR IDENTIFlES DEBTOR
la
~ re
'
p
ces a previousyy filed claim, dated
Check bare ri lliis Claiin
amends
1. BASIS FOR CLAIM
~ Goods sold ^ Retiree Dene/its as defined in 11 U.S.C. 4 11141a)
^ Services performed ^ Wages. salaries, end compensation (Fill BN below)
^ Money loaned Your Social security number
Personal injury/wronglul death Unpa~tl compensation for services pedormetl
Taxes to
hon+

~ Other (Describe briefly) (date)
(date)
2 DATE DEBT WAS INCURRED 3. IF COURT JUDGMENT, DATE OBTAINED:
4. CLASSIFICATION OF CLAIM, Under the Bankruptcy Cade all claims are classifie0 as one or more of the lolkxeing: (1) Unsecuretl nonprioriry.
(2) Unsecured Priority, (9) Secured. It is possible for part W a claim to be in one category end part in anoMer.
CHECK THE APPROPRIATE BO%OR BO%ES that best describe your claim and STATE THE AMOUNT OF THE CLAIM AT TIME CASE FILED.
O SECURED CLAIM A Specity the priority of the claim.
Attach evidence d pertection W eecurrty interest 0 Wages. saaries, rn commissions (up to Ss000).' earnetl not mae then
Brie) DesCriplipn W Collateral: 90 days belwe filing of the bankruptcy petition or Cessation W the Oebtd's
O Real Fatale ^MOfO/ VehiCb ~ Other (Describe briefly) business, whichever is earlier-11 U.SC.{ 507(a)(0)
^ Contributions to an employee benefit plan-11 U.S.C. 4 5D7(e)(1)
Amount of arrearage and other charges at time case filetl includetl in secured O Up to 51,800' W deposits toward purchase, lease, or rental of property or
claim above, a any S services for personal. lamily, or househWO usa-II U.S.C. ~ (507)(a)(6)
^ UNSECURED NONPRIORITY CLAIM S ~ Alimony, maintenance, a support owed to a spouse, loaner spouse, or chiltl-
Aclaim is unsecured a there is no collateral or lien on properly of the 11 U.S.C. 4 507(a)(7)
Oebta securing the claim or to the extent that the value of such O saxes a perxaies d governmental units-1 t U.S.C. 6 507(a)(B)
property is less than the amWnt W the claim. ^ Other~SpeCily applicable paragraph of 11 U.S.C. { 507(x)
'Amounts are suDlect to adlustment on x/1/98 and every 3 years Ihereafler with
^ UNSECURED PRIORITY CLAIMS respect to cases commencetl on or agar date of adlustment.
5. TOTAL AMOUNT OF
CLAIM AT TIME S S S f
CASE FILED: (Unsecured) (Secured) (Priority) (TOlap
D Check this Dox d claim includes charges in adtlrtion to the principal amount of the claim. Attach itemized sutemem o/ all adtlilional charges.
8. CREDITS AND SETOFFS: The amount of all payments on this claim has been credhetl and deducted for Ina purpose THIS SPACE IS FOR
of making this proof of Claim, In /fling this cbim, cbimani has deducted all amounts that claimant owes to debtor. COURT USE ONLY
7. SUPPORTING DOCUMENTS: AaarA muses o1 maoram ~+~ such as promissory notes, purchase orders.
inwices, itemlzetl statements Of running aCCbu MS, contracts, Court ludgmenl5. or andante W security interests. It the
Oocumems are not available, explain. If the tlocuments are wluminous, attach a summary.
8. TIME-STAMPED COPY: To receive an acknowledgement of the fil,ng of your claim, enclose a clamped, sea-addressed
envelope and copy o/ this proof of claim.
Dale Sign and print (he name and Title, d any, of the creditor or other person
aulnorized to file this cWim (attach copy of power of attorney. d any)
Penalty for presenting fraudulent claim: Foe of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C.44 152 and 357t.
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