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United States Bankruptcy Court for the District of are • • • Buffets Restaurants Holdings, Inc., et al. Claims Proces Center c/o Epiq Bankruptcy Solutions, LLC THIS SPACE IS FOR COURT USE ONLY FOR Station, P.O. Box 5286 New York, NY 10150-5286 Name of Debtor Against Which Claim is Held: Case No. of Debtor: NOTE: arising after the commencement of the case. A request for payment of an admini,tralh, expense may be riled pursuant it) I I U.S.C. § 503. Name and address where notices should be sent: BFI(CREDITOR.DBF,CREDNUM)CREDNUM 111000084715....11 ❑ Check this box to indicate that his BAR(23) MAILED •" 000058916108 4** claim amends a previously filed claim. SAN JOAQUIN COUNTY, CALIFORNIA Court Claim 222 E WEBER AVE RM 610 Number: OFFICE EMERGENCY SERVICES Pfknown) STOCKTON, CA 95202 Filed on: ❑ Check this box tryout are aware flet anyone else has filed a pmofofclaim Telephone number: Email Address: relating to your claim. Attach copy of statement giving particulars. Name and address where payment should be sent (if different from above) : Tuts SPACE is FOR COURT URE ONUY 5. Amount of Claim Entitled to Priority under It U.S.C. §507(a). If any portion of your claim falls in one of the following categories, check the box and state the amount. Telephone number: Email Address: ❑ Domestic support obligations under I1 U.S.C. § 507(a)(1)(A) or (a)(1)(B). ❑ Wages, salaries or commissions (up to $11,725), earned within 180 days before filing I. Amount of Claim as of Date Case Filed: $ If all or part of your claim is secured, complete Item 4. of the bankruptcy petition or cessation of the debtor's business, whichever is earlier - I 1 If all or part of your claim is entitled to priority, complete item 5. U.S.C. § 507(a)(4). If all or part of your claim qualifies as an Administrative Expense under 11 U.S.C. §503(b)(9), complete Item 6. ❑ Contributions to an employee benefit plan - LI Check this box if claim includes interest or other charges in addition to the principal amount of the claim Attach 1 I U.S.C. § 507(a)(5). itemized statement of interest or additional charges. ❑ Up to $2,600 of deposits toward purchase, lease, or rental of property or services for 2. Basis for Claim: (See instruction #2 on reverse side) personal, family, or household use - 11 U.S.C. 3. Last four digits of any number by which creditor identities debtor: § 507(a)(7). 3a. Debtor may have scheduled account as: See instruction #3a on reverse side ❑ Taxes or penalties owed to governmental units - 11 U.S.C. § 507(a)(8). 4. Secured Claim (See instruction #4 on reverse side) Check the appropriate box if your claim is secured by a lien on property or a right of setoffand provide the requested ❑ Other — Specify applicable paragraph of 1 I information. U.S.C. § 507(a)(_). Nature of property or right of setoff ❑ Real Estate ❑ Motor Vehicle ❑ Other Amount entitled to priority: Describe: Value of Property: $ Annual Interest Rate % ❑ Fixed or ❑ Variable $ (when case is filed) Amount of arrearage and other charges as of time ease filed included in secured claim, if any: *Amounts are subject to adjustment on 411113 $ and every 3 years thereafter with respect to cases commenced on or after the date of Basis for perfection: adjustment. Amount of Secured Claim: $ Amount Unsecured: $ 6. Amount of Claim that qualifies as an Administrative Expense under 11 U.S.C. §503(6)(9): $ (See instruction #6 on reverse side) 7. Credits: The amount of all payments on this claim has been credited for the purpose of making this proof of claim. (See instmetron #7 on reverse side) 8. Documents: Attach redacted copies of any documents that support the claim, such as promissory notes, purchase orders, invoices, itemized statements of running accounts, contracts, judgments, mortgages and 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 on reverse side and definition of "redacted'). DO NOT SEND ORIGINAL DOCUMENTS. ATTACHED DOCUMENTS MAY BE DESTROYED AFTER SCANNING. If the documents are not available, please explain: 9. Signature: (See Instruction #9 on reverse side) Check the appropriate box: ❑ I am the creditor ❑ I am the creditor's authorized agent. ❑ I am the trustee, or the debtor, or their ❑ I am a guarantor, surety, indorser, or other codebtor. (Attached a copy of power of attorney, if any) authorized agent. (See Bankruptcy Rule 3004.) (See Bankruptcy Rule 3005.) 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. Print Name: Title: Company: Address and telephone number (if different from notice address above): (Signature) (Date) Telephone number: email: Penalty for presenlingfraudulent claim: Fine ofup to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §§ 152 and 3571.