GENERAL53842

• Permit No: M1977376
• IBM Index Class Name: General Documents
• Doc Name: AMENDMENT COVER SHEET
• Media Type: D
• Archive: No

UNITED STATES BANKRUPTCY COURT PROOF OF CLAZM
District of Utah, Centrsl Division
In re (Naam of Debtor) Gee MusOar
MOTE: This }oro should rot ba used to make a claim for an adeiniatrative axparra ar(sirq titer the
eosaMVreeamnt o} LM cues. A request for paMnent of en edai ni stntfve axpenae rY be files pursuant
to n u.f.c s sa3.
Name of Creditor (The person or other entity to whom CHECK BO% if you ae awn that anyan
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the debtor owes exxwry or property.) else hu filed a proof of claim elating
to your claim. Attach a tapy or sLtement
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Name and Addrsas tfiae Notice Should Ba Sent:
CHECK BD)f i} you nawr neeivsd any notice
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}rm the barN:ruptey east in ihb up.
CNECK BOK if thin addreaa ditfera frm the
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addrea on the snwlapa sent to yeu by the THIS (PACE IS FOR
court. COURT USE ONLT
ACCOUNT OR OTXER NUMBER BY YXICN CREDITOR IDENTIFIES Cheek here 1f this elalm _ replaces __ amends s previously filed clslm
DEBTOR: dated:
9. BASIS FOR CLAIM
_ Goods sold _ Reti roe hens}ib es defined in _ WBas, talarf ea, and cammiscions (Fill out bel w)
_ Servi ees performed 11 U.S.C. i 9116(a) Your social security rxarber
_ Money loaned Texea Unp id eospenatian for services performed frm
Personal injury/ _ Other (Describe Briefly) to
+
wrongful death (date) (date)
2. DATE DEBT WS INCURRED: 3. IF COURT JUDGMENT, DATE OBTAINED:
b. CLASSIFIGTION Of CLAIM. Urdar the Bankruptcy Code ell elaiem are elusifiad u one or more of the following: (1) Unsecured
naprfority, (2) Unsecured Priority, (3) Secured. It is possible for part of • elafm to b. in one category, end pert in
arothar. CNECK THE APPROPRIATE BO% OR BO%ES that best dnerlW your claim erd STATE THE AMOUNT OF THE CLAIM.
SECURED CLAM t WSEQIRED PRIOR(iT CLAIM f
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Attach evidence of perfection of security Interest.
Specify the priority of the claim:
Brief dneri ption of Collateral: _ Wges, wlartn, or eoamf ssforo tup to }2000, earned rot more
_ Reel Estate _ Other (Dneriba briefly) then 90 days before }fling of the bankruptcy petition or
Motor Vehicle casatlon of the debtor's 6usinss, whichever to earlier.)
Aorant of arrearspe and other charges ircluded in 19 U.S.C. S 507(x)(3)
secured elsi^ above, if any, f _, Centributian to an aeployaa benfit Plan. 11 u. S. C. §507(a)(b)
UNSECURED NONPR IORItY CLAIM f ,_ Up to f900 of deposits towrd purchase, leace, or rental of
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A claim la urneeurad if there ie ro collateral or lien property or servleaa for peraanl, fam(ly, or household use
an property of the debtor securing the elalm or to the 11 U.S.C. ! 507(x)(6)
extent that the value of such property is lass then the _ iaxp or pwrltia of govarromntal units. 1f U.S.C. 4507(a)(7)
amount of the claim. Other. 1t U.S.C. S1 507(x)(2), (a)(5) (Describe briefly.)
S. TOTAL AMOUNT OF CLAIM f f f
AT TIME GSE FIlEO: (Unsecured) (Secured) (Priority) f f
r-1 CHECK thin boa If claim includes prepetitim charges to eddit ton to the pri nci pl arrant of I
u (ToteU
the elms. Attach itemized statement of all eddi tiara) charges.
6. CREDITS AND SETOFFS: The aasxnt of all payments an thin eld^ hu been credited and dadstsd for THIS SPACE IS FOA
the purpose of rki rag this proof of claim. [n filing this elaL, alai stunt hp dxal+eted all COURT uSE ONLY
amounts that claiar+t owes to debtor,
7. SUPPORi[MG DOCINEMTS: Attach conies of sueoortins daeunenta, such u prmiaaory rotes, purchua
orders, fmoien, itemized stsemients of taming accounts, contracts, court judgments, or
evidarce of security interests. If~the doeumenta ere not available, explain. I} the da:uments
are vol uefnas, attach ^ summary.
Dste Sign and pr/nt the name and title, If any, o} eM eredl for x other person
wthortzed to Hla this ales lm. (Attach copy of powr o} xttorrry, (} yry.)
Para lty for Present irq Fratlilent Claim: Fin of uP to (5,000 or ir~risoreaent for up to'S yearn or both. 19 U.S.C. §§ 952 L 3579