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FORM oto United States Bg ruptcy Court P70007390 18 6/90 95231 9291781 EASTERN DISTRICT OF CALIFOki4IA SVOTTY'S BAIT & TACKLE, INC. 574 W. GRANTLINE RD. IN RE (NAME OF DEBTOR) TRACY, CA 95376 SCOTTY'S BAIT & TACKLE, INC. CASE NUMBER: PROOF OF CLAIM 92-91781 NOTE: This form should not be used to make a claim for an administrative expense arising after the i commencement of the case. A "request" of payment of an administrative expense may be filed pursuant to 11 U.S.0 section 503. I i i ❑ Check box if you are aware that ❑ Check box if you have never ❑ Check box If the address differs anyone else has filed a proof of received any notices from the from the address on the envelope claim relating to your claim. Attach bankruptcy court in this case.sent to ou b�y the court. copy of statement giving particulars. INDICAT CHANGE OF ADDRESS BELOW: YOUR CREDITOR NO. IS: 0000022 PUBLIC HEALTH SERVICES P.O. BOX 2009 ENVIRONMENTAL HEALTH STOCKTON, CA 95201-2009 f�frl�r�nf�f��nnfl��n�1��nf��nf�I�nf1�1 U. S. BANKRUPTCY COURT CLAIMS DEPARTMENT P. 0. BOX 5376 111111111111111111!11111111111111611�IIIIIInIAllnllnl�lAl 9291781FI0000022 THIS SPACE IS FO COURT USE ONLY ACCOUNT OR OTHER NUMBER BY w TCH CREDITOR IDENTIFIES DEBTOR: E] replaces Check here If this claim a previously filed claim, dated: ❑ amends 1. BASIS FOR CLAIM El Money loaned ❑ wap—, salaries. and compensations (Fill out bele.) ❑ sold ❑ Personal ,njury/wrongful death Your social security number �p mGoods a 11Services perfored ❑ Texas i� ❑ Other (Describe briefly) Unpei compansat ion�� vL lces perfo ..d� ,1�t/-'{it�/,,1��`I Olt ❑ Ratirao benefits as defined In 11 U.S.C. section 1114(a) fro'_^.-- _ I date) luate) 2. DATE DEBT WAS INCURREDrAto 1yp TqN I 3. IF COURT JUDGEMENT, DATE OBTAINED: 4. CLASSIFICATION OF CLAIM. Under the Bankruptcy Code all claims are classified as one or more of the following: (1) Unsecured nonpriority, (2) Unsecured Priority, (3) Secured. It is possible for part of a claim to be in one category and part In another. CHECK THE APPROPRIATE BOX OR BOXES that best describe your claim and STATE THE AMOUNT OF THE CLAIM. ❑ SECURED CLAIM 5 ❑ UNSECURED PRIORITY CLAIM 5 Attach evidence of perfection of security interest Specify the priority of the claim. Brief Description of Collateral: ❑ Wages, salaries, or commissions (up to 82000), earned not more than ❑ Real Estate ❑ Motor Vehicle ❑ Other (Describe briefly) 90 days before filing of the bankruptcy petition or cessation of the debtor's business, whichever is earlier) — 11 U.S.C. see. 507(a)(3) Amount of arrearage and other charges included in secured claim above. ❑ Contributions to an employee benefit plan — U.S.C. sec. 507(x)(4) if any 5 ❑ Up to 5900 of deposits toward purchase, lease, or rental of property or ❑ UNSECURED NONPRIORITY CLAIM 5 services for personal, family, or household use -11 U.S.C. sec. 507(x)(6) A claim is unsecured if there is no collateral or lien on property of the debtor *uring the claim or to the extent that the value of such ❑ Taxes or peneltiA of govermental units — 11 U.S.C. sec. 507(a)(7) propertlfd,is less than the amount of the claim. Other — 11 U.S.C. sections 507(a)(2), l9)(5)— (Describe briefly) S. TOTAL AMOUNT OF �/ z 7D CLAIM AT TIME 5 5— 5 — 5 11 CASE FILED: (Unsecured) (Secured) (Priority) (Total) ❑ Check this box if claim includes prepetition charges in addition to the principal amount of the claim. Attach itemized statement of all additional charges 6. CREDITS AND SETOFFS: The amount of all payments on this claim has been credited and deducted for the purpose of making this proof of claim. In filing this claim, claimant has deducted all amounts that claimant owes to debtor. 7. SUPPORTING DOCUMENTS: Attach copies of supporting documents, such as promissory notes, purchase orders, Invoices, Itemized statements of running accounts, contracts, court judgements, or evidence of security Interest. If the documents are not available, explain. If the documents are voluminous, attach a summary. 8. TIME—STAMPED COPY: To receive an acknowledgement of the filing of your claim, enclose a stamped, self—addressed envelope and copy of this proof of claim. Date Sign and print the name and title, If any, of the creditor or other person authorized to file this claim (attach copy of power of attorney, if any) THIS SPACE IS FOR COURT USE ONLY Penalty for presenting fraudulen. n: Fine of up to 1500,000 or imprisonment for up t /ears, or both. 19 U.S.C. sections 152 and 3571.