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MAIL ORIGINAL AND I rr) GC) IF O ARRIVE NO LATER THA UNITED STATES BANKRUPTCY GOURT PROOF OF CLAIM Nonhom District of California .John Breuner Company aka Brecrners Ar!Crest. {:nr?r:;ion if Required Imo'' t+ca4 San Joaquin City Public Heal P 0 box 2009 Stockton, CA 95201 refeohone Ir: amount of t ?8R.6n Case Number 93-47076-J ❑ (:ho -:k box if you are aware that anyone else has filed a proof of claim relating to your claim. Attach copy of slaternent giving particuiam. ❑ Check box ii you have never received any notices from the bankruptcy court in this rase. U Check box it the address differs from rhe address on the envelope sant to you by the court. NUARY 31, 1994._ THiS SPACE IS FOR COURT USE ONLY Check here ❑replaces if this claim ,ends filed daim, dated ❑ amends rb} - form is appropriate gajy jor claims relating 4 CLASSIFICATION. OF CLAIM Under dw Bankruptcy Code all daunt are ciatsified as one ar mora of the rn .*»Boon with 9 rhnna Wt [a [October 6, ioij inq- f +1 I tnewcurad nnnnriorlty. (9) Unsocured priority tai gaeur,sr: h ho Paaalide ler pen of a aleim M I4o 1 If not resolve in tfle ordlnery tours@ or be in one category and part in another. 5tlsiness, claims relating to dealings with CHECK THE APPROPRIATE BOX OR BOXES that best describe your claim and STATE THE AMOUNT arr3uners aft@ -E October 5, 1993 are adminis- OF THE CLAIM. +rrivve expanses under 11 U.S.C. §503 and e , lymenf must be requested by motion to the ❑ SECURED CLAIM $ nurt, not on this form. El evidence of perfection of recur ty interest 13ASIS FOR CLAIM: LJ Real Estate ❑ Motor Vehicle ❑ Other {Describe briefly) f—I Goods soid Amount of arrearage and other charges included in secured claim above. -`q it any {.J Services performed ❑ fl?llree benefits as defined in 11 U.S.C. +j 1114(o ❑ UNSECURED PRIORITY CLAIM # tJ Money loaned Specify the priority of the Claim. I J Personal tn)uryhvrongful death ❑ Wages. sAlariss, or commissions (up to $2000), awned not more J Taxes than qo days before filing of the bankruptcy petition or cessation of itro dabloO s business, whichever is earlier) - 11 U.S.C. § 507(a)(3) i Other Pescribe briefly) ❑ Contributions to an employee benefit plan - 11 U.S.C. § 507(8)(4) Wages, salaries, and compensation iFill out below) © Up to $900 of deposits toward purchase, lease, or rental of property or services for personal. Iamily, or household use - 11 U.S.C. § 507(a)(6) Your sociat security number ❑ Tates or penaldes of governmental units . 11 U.S.C. § 507(a)(7) I Unpaid compensation for services performed ❑ Other - 11 U.S.C. §§ 507(a)(2). (a)(S) • (DawAbe briefly) ❑ UNSECURED NONPRIORITY CLAiM = from to� A claim is unsecured if there A no Collateral or lien on property of fie debtor !mr_ttnng to ^Iaim or to the extent that the value of such property is lata than(date) (caro) i the amount of the claim - I )ATE FEST WAS INCURRED: 5, TOTAL AMOUNT OF CLAIM AS OF OCTOBER S, 1993 i —..-- ❑ Ch,.* this box it claim 'includes prepetition charges in addition to the principal amount o1 trip. cairn - Attach itemized statement of ail additional charges. ~1 IF COURT JUDGMENT, DATE OBTAINED: _ v F; -PFDOS AND SETOFFS: The amount of all payments of this r.laim h:t1 been creditrxi and deducted for the THIS SPACE IS FOR nIrtnose of making this proof of dwm. In Ong tnis ctaim.l.dllld ham t f+ad Ad314t�d all am4unta chat ci 'inset owe@ COURT USE ONLY 7. SUI'PORTING DOCUMENTS. Attach copies of supporting documents, such as promissory notes, purchase orrers, :nwicea, itemized statements of running accounts, ciontrar_ts, court judgments, or evApnoo of security imerest, If the documents are not available, explain. If the documents are voluminous. attach a summary. a rimF STAMPED COPY. To receive an acknowledgmAnt of the filing of your claim. anciosa a stamped, q,""addressed envelope. r)hre `Sign and print the name and dila, if any, of the creditor or other person authorized to file th+s claim (ar[ach copy of power of attorney, 'if any) iry rnr nrnsenOng fraudulent claim: Fine of up to $500 or irnprisonmonr for up to 5 years, or both. i8 U.S.0 §§ 152 and 3571. )tic incl signature required. Send original and two (2) copies to- U.S.B.C., Coo Breuners Claims Administrator, 1300 Clay Street, Suite 300, Oakland, CA 94612 to ai ye no later than January 31, 1994.