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0 BIO (Official Form 10) (04110) 0 UNITED STATES BANKRUPTCY COURT Northern District of California PROOF OF CLAIM Name of Debtor: James Michael Hartington Case Number: 10.49577 Sheryl Rae Hartington NOTE: This form should not he used to make a claim Jar an administrative expense arising after the commencement of the case. A request for payment of an administrative expense mbefiledisursuaw to 11 U.S.C. § 503. Name of Creditor (the person mother entity to whom the debtor owes money or property): I]Check this box to indicate thin this claim San Joaquin County amends a previously filed claim. Name and address where notices should be sent: San Joaquin County Court Claim Number: Enviromemal Hrrl(h Department (1f known) 600 E Main Street Stockton, CA 95202-3029 Telephone number. Filed on: Name and address where payment should be sent (if different from above): E3Check this 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 this box if you are The debtor or trustee Telephone number. in this case. 1. Amount of Claim as of Date Case Filed: $ S. Amount of Claim Entitled to Priority under 11 U.S.C. §507(a)• V any portion of your If all or pan of your claim is secured, complete item 4 below; however. if all of yourclaim is unsecured, do not claim falls in one of the following categuries, complete item 4. check the box and state (he amount. If all or pan of your claim is entitled to priority, complete item 5. OCheek This box if claim includes interest or other charges in addition to the principal Mount of clean. Attach Specify the priority of the claim. itemized statement of interest or charges. Momeslic support obligations under 11 U.S.C. §507(a)(1 XA) or(a)(lT(B). 2. Basis for Claim: (See instruction #2 on reverse side.) DWages. salaries, or commissions (up to $11,725•) earned within 180 days before 3. Last four digits of any number by which creditor identifies debtor: filing of the bankruptcy petition orcessation 3a. Debtor may have scheduled account mu of the debtors business, whichever is earlier (See instruction #ia on reverse side.) - 11 U.S.C. §507 (a)(4). ClConerihutions to an employee benefit plan - 11 4. Secured Claim (See instruction #4 on reverse side.) Check the appropriate box if your claim is secured by a lien un property or a rigid of setoff and provide the U.S.C. §507 (al(5). requested information. Nature of property or right of setoff: E3Rcal Esme Q Manor Vehicle E3 Other I7Up to $2,600+ of deposits toward purchase, lease, or rental of Property or services for Describe: personal, family, or household use - I I U.SC. Value of Properly:$ Annual Interest Rale_ _% §507(a)(7). or penalties owed to governmental units Amount of arrearage and other charges as of time case filed included In securedMuses claim, - 11 U.S.C. §507 (a)(8), if any: $_ Basis for perfection: Other -Specify applicable paragraph of 11 Amount of Secured Claim: $ Amount Unsecured: $ U.S.C. §507(a)( _). _ 6. Credits: The amount of all payments on this claim has been credited for the purpose of making this proof of claim. Amami entitled to prlaily: 7. 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. $. You may also attach a Summary. Attach redacted copies of documents providing evidence of perfection Of a security interest. You may also much a summary. (See instruction 7 and definition of "redacted' on reverse side.) DO NOT SEND ORIGINAL DOCUMENTS. A7TACIIED DOCUMENTS MAY BE DESTROYED AFTER *Amounts are subject to adjustment on 411113 SCANNING. and every 3 years thereafter with respect to cases commenced on or after the dare of If the documents are not available, please explain: adjustment. Date% Signature: The person filing this claim must sign it Sign and print name and title, if any, of the creditor or other FOR COURT USE ONLY person authorized to file this claim and state address and telephone number if different from the notice address above. Attach copy of power of attorney, if any. enarry for presenting frauautent ctmm: Nine of up to y5W,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §§ 152 and 3571. 024988 73704025012027