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Individual, Joint, Corporation <br /> Partnership, Fins or Agency tL-7978, HaIESTF.AU SAVINGS, A FERAL SAVINGS AMID LOAN ASSOCIATION <br /> (Name of Bank/financial Institution and Location) <br /> Claim No. <br /> PROOF OF CLAIM <br /> SU/Tax ID $ <br /> The undersigned <br /> (Name of Person making the Claim) <br /> states that the HO67-S"ITFAD SAVINGS, A FEDERAL SAVINGS AMID IRAN ASSOCIATIai now in Liquidation is justly <br /> (Name of Bank/Financial Institution) <br /> indebted to in the sins of <br /> (Individual/Joint/Corporation/Partnership/FinVAgency) <br /> Dollars upon the following claim: <br /> Account Type Liability Number Uninsured Principal Liability Number Uninsured Interest <br /> D <br /> E <br /> P <br /> 0 <br /> S <br /> I <br /> T <br /> S <br /> Total P & I <br /> Description of (invoice) Claim: Liability Number Amount of Claim <br /> C <br /> L <br /> A <br /> I <br /> M <br /> S [Total Claim: <br /> Undersigned further states that he/she makes this claim an behalf of <br /> and that no part of said debt has been paid, that <br /> (Individual/Joint/Corporation/Partnership/Fins/Agency) <br /> has given no endorsement or assignment of the same or any part thereof and that there is no set-off or counterclaim, or other <br /> legal or equitable defense to said claim or any part thereof. <br /> NAME <br /> (Signature of Person making the Claim) (Title) <br /> FIRM <br /> (if applicable) <br /> ADDRESS <br /> CITY/STATE/ZIP <br /> TELEPHONE: LIATFID <br /> THE PENALTY FOR KNOWINGLY MAKING OR INVITING RELIANCE ON ANY FALSE, FORGED, OR COUNTERFEIT STATEMENT, DOCLMENT, OR THING FOR <br /> THE PURPOSE OF INFLUENCING IN ANY WAY THE ACTION OF THE RESOLUTION TRUST CORPORATION IS A FINE OF NOT MORE THAN $1,000,000 OR <br /> IMPRISONMENT FOR NOT MORE THAN TWENTY YEARS, OR BOTH (18 U.S.C. 1007). <br />