Form B10 (10/05) - Proof Of Claim - New York printable pdf download

UNITED STATES BANKRUPTCY COURT

PROOF OF CLAIM

SOUTHERN DISTRICT OF NEW YORK

THIS SPACE IS FOR COURT USE ONLY

(Manhattan Division)

Specific Debtor against which this claim is asserted:

NOTE: This form should not be used to make a claim for an administrative expense arising after the

commencement of the case. A "request" for payment of an administrative expense may be filed pursuant

to 11 U.S.C. § 503.

Name of Creditor (The person or other entity to whom the debtor owes money or property):

Name and address where notices should be sent:

Check box if you are aware

that anyone else has filed a

proof of claim relating to your

claim. Attach copy of

statement giving particulars.

Check box if you have never

received any notices from the

bankruptcy court in this case.

TEL:

(

)

Carefully read instructions included with this Proof of Claim before completing. In order to have your claim considered for payment and/or voting purposes, complete ALL applicable questions. The

original of this Proof of Claim must be mailed to: United States Bankruptcy Court, Southern District of New York, Attn: Refco Inc. Claims Docketing Center, Bowling Green Station, P.O.

Box 5175, New York, New York 10274-5175 or hand delivered to: United States Bankruptcy Court, Southern District of New York, Attn: Refco Inc. Claims Docketing Center, One Bowling

Green, Room 534, New York, New York 10004-1408. This Proof of Claim must be received no later than July 17, 2006, at 5:00 p.m. prevailing Eastern Time. No facsimiles will be accepted.

Check here

Last four digits of account or other number by which creditor

A previously filed claim, dated:

Replaces

if this claim

identifies debtor:

Amends

Number:

1. Basis for Claim

Tax Payer Identification #:

Taxes

Retiree benefits as defined in 11 U.S.C. § 1114(a)

Last 4 Digits of Your Social Security #:

Goods sold

Services performed

Wages, salaries, and compensation (fill out below)

Money loaned

Unpaid compensation for services performed

Personal injury/wrongful death

from (mm/dd/yyyy):

to (mm/dd/yyyy):

Other:

3. If court judgment, date obtained:

2. Date debt was incurred:

yyyy

Check the appropriate box or boxes that best describe your claim and state the amount of the claim at the time case filed.

4. Classification of Claim.

See reverse side for important explanations.

Secured Claim

Unsecured Nonpriority Claim

Check this box if your claim is secured by collateral (including a right of

setoff).

Check this box if: a) there is no collateral or lien securing your claim, or b) your

Real Estate

Motor Vehicle

Brief Description of Collateral:

claim exceeds the value of the property securing it, or c) none or only part of your

Other:

claim is entitled to priority.

Unsecured Priority Claim

Value of Collateral:

Check this box if you have an unsecured priority claim, all or part of which is

Amount of arrearage and other charges included at time case filed included in secured claim, if any:

entitled to priority.

Amount entitled to priority:

Contributions to an employee benefit plan - 11 U.S.C. § 507(a)(5).

Specify the priority of the claim:

Up to $2,225* of deposits toward purchase, lease, or rental of property or services for personal,

Domestic support obligations under 11 U.S.C. § 507(a)(1)(A) or (a)(1)(B).

family, or household use - 11 U.S.C. § 507(a)(7).

Taxes or penalties owed to governmental units - 11 U.S.C. § 507(a)(8).

Wages, salaries, or commissions (up to $10,000),* earned within 180 days before filing

Other - Specify applicable paragraph of 11 U.S.C. § 507(a)

(________).

of the bankrupcty petition or cessation of the debtor's business, whichever is earlier - 11

*Amounts are subject to adjustment on 4/1/07 and every 3 years thereafter with respect to cases commenced on or

U.S.C. § 507(a)(4).

after the date of adjustment.

5. Total Amount of Claim at Time Case Filed:

$_____________________

_____________________

(unsecured)

(secured)

(priority)

(total)

Check this box if claim includes interest or other charges in addition to the principal amount of the claim. Attach itemized statement of all interest or additional charges.

THIS SPACE IS FOR

6. Credits: The amount of all payments on this claim has been credited and deducted for the purpose of making this proof of claim.

7. Supporting Documents: Attach copies of supporting documents, such as promissory notes, purchase orders, invoices, itemized statements

COURT USE ONLY

of running accounts, contracts, court judgments, mortgages, security agreements, and evidence of perfection of lien. DO NOT SEND

ORIGINAL DOCUMENTS. If the documents are not available, explain. If the documents are voluminous, attach a summary. Failure to

provide appropriate documentation may result in your claim being subject to objection.

8. Date-Stamped Copy: To receive an acknowledgment of the filing of your claim, enclose a stamped, self-addressed envelope and copy of

this proof of claim.

SIGN and print the name and title, if any, of the creditor or other person authorized to file this claim (attach power of attorney, if any).

Signature

Date (mm/dd/yyyy)

Printed Name

Title

0001

Penalty for presenting fraudulent claim: Fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §§ 152 and 3571.

POC0001

Form B10 (10/05) - Proof Of Claim - New York

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