Proof Of Claim Form - State Of Alabama Department Of Insurance printable pdf download

For Official Use Only:

Claim No: _______

STATE OF ALABAMA DEPARTMENT OF INSURANCE

WEST ALABAMA MEMORIAL GARDENS, INC.,

HERITAGE MEMORIAL GARDENS, INC., HERITAGE

MONUMENT COMPANY, INC. AND HAMILTON

MEMORY GARDENS, INC.

IN LIQUIDATION

PROOF OF CLAIM FORM

This Proof of Claim must be completed, signed under oath, and sent by first class mail to Denise B. Azar,

Receiver, West Alabama Memorial Gardens, Inc., Heritage Memorial Gardens, Inc. and Hamilton

Memory Gardens, Inc., Post Office Box 303353, Montgomery, AL 36130-3353, Attn: Proof of Claim.

This Proof of Claim should be sent as soon as possible, but MUST BE FILED NO LATER THAN October

16, 2006, OR THE CLAIM MAY BE DENIED.

PLEASE READ THE ACCOMPANYING NOTICE AND INSTRUCTIONS BEFORE COMPLETING THIS

FORM. Mark “NA” or “Not Applicable”, where appropriate. PLEASE TYPE OR PRINT. A SEPARATE

PROOF OF CLAIM SHOULD BE COMPLETED AND FILED FOR EACH CLAIM.

You are making this claim as (mark one):

Individual

Corporation

Partnership

Agent

Other

Please explain if other: _________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________

Please set forth the name, address and phone number of the claimant:

Claimant Name (As it appears on contract): ______________________________________________________

Point of contact if different from claimant: __________________________ Phone: _____________________

Street Address: _______________________________________________________________________________

City_______________________________ State_____ Zip ___________ Phone___________________________

This claim is filed as a (n) unsecured

secured

claim. (Mark one.)

Total Amount Claimed $ ________________________ Date claim was incurred________________________

Contract/Account #: _________________________________________________________________________

Purchased from following location:

West Alabama Memorial Gardens, Inc.

Heritage Memorial Gardens, Inc.

Heritage Monument Company, Inc.

Hamilton Memory Gardens, Inc.

Explanation of Claim.

Please attach documentation to support claim amount. Attach additional sheets if necessary.

1. The consideration for this debt (or ground of liability) is as follows:

_____________________________________________________________________________________________

2. If this claim is founded on a written instrument, please attach a copy of such written instrument or if it

cannot be attached please set forth the reason therefore.

_____________________________________________________________________________________________

OVER (COMPLETE OTHRR SIDE)

POC Form (Revised 01/2006)

Page 1

Proof Of Claim Form - State Of Alabama Department Of Insurance

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