Form B10 - Proof Of Claim (Page 2 of 2) in pdf

Form B10 - Proof Of Claim Page 2

B 10 (Modified Official Form 10) (4/13)

6. Credits. The amount of all payments on this claim has been credited for the purpose of making this proof of claim. (See instruction #6)

7. Documents: Attached are redacted copies of any documents that support the claim, such as promissory notes, purchase orders, invoices, itemized statements of

running accounts, contracts, judgments, mortgages, or security agreements. If the claim is secured, box 4 has been completed, and redacted copies of documents

providing evidence of perfection of a security interest are attached. (See instruction #8, and the definition of “redacted”.)

DO NOT SEND ORIGINAL DOCUMENTS. ATTACHED DOCUMENTS MAY BE DESTROYED AFTER SCANNING.

If the documents are not available, please explain:

8. Signature: (See instruction #8)

Check the appropriate box.

❐ I am the creditor.

❐ I am the creditor’s authorized agent.

❐ I am the trustee, or the debtor,

❐ I am a guarantor, surety, indorser, or other codebtor.

or their authorized agent.

(See Bankruptcy Rule 3005.)

(See Bankruptcy Rule 3004.)

I declare under penalty of perjury that the information provided in this claim is true and correct to the best of my knowledge, information, and reasonable belief.

David Verderame

Print Name: _________________________________________________

Class Representative

Title:

_________________________________________________

Company:

_________________________________________________

Address and telephone number (if different from notice address above):

(Signature)

(Date)

301 Clifford Road, Selingsgrove, PA 17870

_________________________________________________