|
United States Bankruptcy Court
<br />1' 9394622 EASTERN DISTRICT OF CALIFORNIA
<br />METER SErVICE, INC.A CALIF. '7"PT•
<br />L$ERT ST. 111 Rr' i31AME OF D BTOR)I,
<br />1.11"'PF'i7 SERVICE, INC!l1cA:rF CORP
<br />h r-
<br />CASE! IlUrli;Fti' 0')
<br />PROOF OF CLAIM 9—aie12L ���1G'�? P
<br />22
<br />NOTE. This form should not be used to make a claim for an nnminlstrntive expense "rising otter the •
<br />cnnlmencemenl of the ease.. A "request" of payment of an administrative expense may be filed pursuant
<br />to 11 U.S.0 section 503.
<br />Chack box if you are aware that EJ Cheek box if you have never _'i Check box It the address differs
<br />anyone else has filed a proof of received any notices from the from the eddress on the envelope
<br />claim raiating to your claim. Attach bankruptcy court in this case. sent to You b the court.
<br />copy of statement giving particulars. INDICATE CHANGE Ct F DDRES. BELOW:
<br />YOUR. CREDITOR 11C). IS: 0000053
<br />cAN JOAQUIN COUNTY
<br />PUBLIC HEALTH SERVICES
<br />F U BOX 2009
<br />STOCETON, CA 95201-2009
<br />lift I,IIrkrIllllllrtrrllllr,I,Illrtrlllrrlrllrllr,rirlrrl Illrl
<br />U. S. BANFRUPTCY COURT 111111IIIIIIIIIIIlIIIIIIIlIIIIIIlIl Illllllllllllllllllllllllullllll>llIIEIIllllllllllllll
<br />CLAIMS DEPARTMENT 9394622RD000053 THIS SPACE IS FOR
<br />1- - C?. BUY. 53 !b COURT USE ONLY
<br />MODES_T�r' 9 53 52
<br />ACCouNl DP oSNeP NUMOZA er WnREM CREDITOR rORNTrr1Es oeetoP 1 Check here If this claim DIreplaees a previously flied claim, dated: I
<br />Fj emends
<br />1 BASIS FOR CLAIM �MbnOy +p/n.a — -- -----`i-- wwoP swl.r,w�, .na CbTDfnSPrIVIS bill pvr Del—)
<br />I
<br />C9DOc
<br />-10 6—tl, Spur Spr 1w1 se urItY n-wt,/r E
<br />--1,
<br />S- s vwrro ed
<br />Li etrlwr IDw/Gr lbP br 1w110 Unpw.1%ee,w.n.nAae 1pnx ter L/rY 1Cw5 Rar}ernH/A
<br />Ret Ir/w bRtl.r lrS /F d., •nwtl In 11 U.S.0 ,twCT ICn Illwl rr erl-- tE
<br />' lastwy in/ta1
<br />2. DATE DEBT WAS INCURRED I1I 3. IF COURT JUDGEMENT, DATE OBTAINED:
<br />CLASSIFICATION OF CLAIM. Under the Bankruptcy Code all claims ore classified as one or more of the following: (1) Unsecured nonpricrity,
<br />d2i Unsecured Priority, (31 Secured. It is possible for part of a ci"im to be in one category and part in another,
<br />;'FiE7.K THE APPROPRIATE BOX OR BOXES that best describe your claim and STATE THE AMOUNT OF THE CLAIM AT TIME CASE FILED.
<br />SECURED CLAIM S— -- ----
<br />Attach evidence of perfection of security interest
<br />Brief Deseription of Collateral:
<br />j,_j Real Estate ❑ Motor Vehicle j] Other IDescribe briefly}
<br />Amount of arrearage and other charges Included In secured claim above.
<br />if any i
<br />UNSECURED NONPRIORITY CLAIM t ---.-. ----- ------------- i
<br />A claim is unsecured if there is no collateral or lien on property of the
<br />debtor securing the claim or to the extent that the value of such j
<br />property is less than the amount of tho claim.
<br />�D UNSECURED PRIORITY CLAIM S -
<br />Specify the priority of the claim.
<br />Wages, salaries, or commissions (up to $2000), earned not more than
<br />90 days before filing of the bankruptcy petfood or cessation of the
<br />debtor's business, whichever is earlier) - 11 U.S.C. sec. 5074)(3)
<br />Contributions to on employee benefit pian - U.S.C. sec. 5071s)(4)
<br />~I Up to $900 of deposits toward purchase, lease, or rental of property o+
<br />services for personal, family, or household use -11 U.S.C. sec. 5071"1([
<br />Taxes or penalties of goywmentel units - 11 U.S.C. sec. 507(")[71
<br />Othe- - Ep±clfy applicabla paragraph. of 11 U.S.C. sections !;V?W
<br />S. TOTAL AMOUNT OF
<br />CLAIM AT TIME
<br />CASE FILED: Wnsocuredl-(Securedl
<br />(Priority)
<br />i
<br />(Total) 1
<br />Chock this box if claim includesprepetltlon chorgnx in ar{rtifion to the principal amount of the claim. Attach Itemized statement of all additionaf efrw,n •.i
<br />S. CREDITS AND SETOFFS: The ampunt of all payments nn this claim has boon credited and deducted for
<br />the purpose of making this proof of claim. In filing this claim, claimant hes deducted all amounts that claimant
<br />owes to debtor,
<br />11 .;LIPPORTING DOCUMENTS: Attach copies of Supporting documents, such as promissory notes, purchase
<br />nrdr•rs, Invoices, Itemized statements of running accounts, contracts, court judgements, or evidence of security
<br />Interest. If the d9cufnent; art, trot available, explain, If the documents are voluminous, altonh a piMmory.
<br />F. TIME -STAMPED COPY: To receive an acknowledgement of the filing of your claim, enclose "stomped,
<br />self-addressed envelope and copy of this proof of claim.
<br />Sign and print the name end title, if any, of the creditor or other person
<br />authorized to file this clnim (attach copy of power of attorney, if any)
<br />THIS SPACE IS FOP
<br />COURT USE ONLY
<br />r
<br />!'r.nr'ty lo'clfine of up to x500,000 or imprisonment for up to 5 s, or both. 18 U.S.C. sections 152 and 3571.
<br />3
<br />
|