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<br />FORM B10 (Official Form 10) (12/03)
<br />mR~~y
<br />
<br />~UxrrED STATES BANKRUPTCY COURT DISTRICT of Colorado PROOF OF CLAIM
<br />Name ofDebtorAgile Stone Systems, Inc. a Case Number
<br />Delaware Corp. Fed ID No. 84-1374872 03-16692ABC
<br />NOTE: This form should not be used to make a claim for an adminis[mdve expense arising after the commencemrnt
<br />of the case. A 'tequesP' for payment of an administrative expense may be filed pursuant to 11 U.S.C. § 503.
<br />Name of Creditor (The person or other entity m whom the debtor owes ^ Check box if you are aware that
<br />money or property): Colorado Department of Public anyone else hasfiledaproofof
<br />Health & Environment, Air Pollution claim relating to your claim. Attach
<br />Control Division copy ofsmtementgiving
<br /> particulars.
<br />Name and address where notices should be sent: ^ Check box if you have never
<br />Thomas A. Roan, Assistant Attorney General
<br />/ received any notices from the
<br />State of Colorado batdwptcy coutt in this rase.
<br />1525 Sherman Street, 5th Floor ^ Check box if the address differs
<br />Denver, CO 80203 from the address on the envelope
<br />Telephone ntunber: 303-866-5280 sent to you by the covrL THIS SPACE IS FOR COURT USE ONLY
<br />Account or other ntunber by which creditor identifies debtor: Con- Check here ^ replaces
<br />struction permit lls: 97P00598; 97P00603; if this claim apreviously filed claim, dated:
<br />O1P00474 ^ amends
<br />1. Basis for Claim
<br />XENE
<br />RE
<br />^ Goods sold nnAA ~/ ^ Retiree benefits as defined in 11 U.S.C. § l 114(a)
<br />^ Services performed , 06 ZDUY ^ Wages, salaries, and compensation (fill out below)
<br />N
<br />^ Money loaned . JA
<br />Last four digits of SS #:
<br />^ Personal injury/wrongful death Geology Unpaid compensation for services perfortned
<br />ls &
<br />^ Taxes piuision of Minera
<br />from to
<br />~ Other Civil Penalty
<br />(ire) ~ (date)
<br />2. Date debt was incurred: 3. Itcourt judgment, date obtained:
<br />01/08/98 - 02/20/03 N/A
<br />4. Total Amount of Claim at Time Case Fled: $ 57 , 75 .00 57, 750.00
<br />(unsecured) (seLwed) (priority) (Total)
<br />If all or part of your claim is secured or entitled to priority, also complete Item 5 or 7 below.
<br />^ Check [his box if claim includes interest or other charges in addition to the principal amount of the claim. Attach itemized statement of all
<br />interest or additional charges.
<br />5. Secured Claim. 7. Unsecured Priority CLtim.
<br />^ Check this box if your claim is secured by collateral (including a ^ Check this box if you have an unsecured priority claim
<br />right of setot~.
<br />Amount entitled to priority $
<br />Brief Description of Collateral: Specify the priority of the claim:
<br />^ Real Estate ^ Motor Vehicle ^ Wages, salaries, or commissions (up to $4,650),* earned within 90
<br />^ Other days before filing of the bankmptcy petition or cessation of the
<br /> debtor's business, whichever is earlier - 11 U.S.C. § 507(a)(3).
<br />Value of Collateml: $ ^ Contributions to an employee benefit plan - 11 U.S.C. § 507(a)(4).
<br /> ^ Up to $2,100* of deposits toward purchasq lease, or rental of
<br />Amount of atrearage and other charges at time case filed included in property or Services for personal, family, or household use - 11 U.S.C.
<br />secured claim, if any: S § 507(a)(6).
<br /> ^ Alimony, maintenance, or support owed [o a spouse, former spouse,
<br />6. Unsecured Nonpriority Claim $ 57.750.00 or child • 11 U.S.C. § 507(a)(7).
<br /> ^ Taxes or penalties owed to governmental units-1I U.S.C. § 507(a)(S).
<br />~ Check this box if: a) there is no collateral or lien securing your ^ Other -Specify applicable pamgmph of I I U.S.C. § 507(a)(_).
<br />claim, or b) your claim exceeds the value of the property secunng it, or 'Amounts are subject ro adjustment on 4/1/04 and every 3 years thereafter with
<br />if c) none or only part of your claim is rntitled to pnonty. respect to carer commenced on or ajier the dare of adjvs+mem.
<br />8. Credits: The amount of all paymrnts on this claim has been credited and deducted for the purpose of making THIS SPACE IS POR COURT USE ONLY
<br />this proof of claim.
<br />9. Supporting Documents: Attach copies of supporting documents, such as promissory notes, purchase
<br />orders, invoices, itemized statements of running accounts, contracts, court judgments, mortgages, security
<br />agreements, and evidence of perfection of lien. DO NOT SEND ORIGINAL DOCUMENTS. If [he doctunents are
<br />not available, explain. If the documents are voluminous, attach a suttunary.
<br />10. Date-Stamped Copy: To receive an aclmowledgment of the filing of your claim, enclose a stamped self-
<br />addressed envelope and copy of [his proof of claim
<br />Date Sign and print the name and title, if any, of the creditor or other person authorized to file
<br />IZ ~ ~, / ~ ~ this claim (attach copy of power of attorney, if any): ~,_.,_ 4r .~~ - --~-
<br />
<br /> c>:tir~:sc_,...ICa..,c ~_~ c.o Plc rk i~~o
<br />Penalty for presenting fraudulent claim: Fine of up to $500,000 or imprisonment for up [0 5 years, or both. IB U.S.C, §§ 152 and 3571.
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