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MAIL ORIGINAL A' ` TWO COPIESTDIf ORRIVE ZNnATER N JANUARY 31 r 1994. <br /> UNITED STATES BANKRUPTCY COURT PROOF OF CLAIM <br /> Northam District of California <br /> in re se John Breuner Company CaNumber <br /> aka Breuners 6-J :'�.ii; J:;,at.; 'a NTH <br /> 93-4707 , - ►'`('f: <br /> NEA <br /> LTH <br /> Correction it Required <br /> ❑Check box if you are aware that 93 NON 19 P-11 2: 28 <br /> anyone also has riled a proof of <br /> Telephone <br /> claim relating to your claim-Attach <br /> #: oopy of statement giving particulars. <br /> Cr San Joaquin City Public Heal El Check box If you have never <br /> received any notices from the �// ff�J _ <br /> P 0 box 2009 bankruptcy court in this case, ice'/ .f� <br /> Stockton, CA 95201 ❑Check box if the address differs <br /> from the address on the envelope <br /> sent to you by the court, 111 iii" <br /> Telephone 9: THIS SPACE IS FOR <br /> COURT USE ONLY <br /> I ldbynreu Check here We"amount of if this claim <br /> ❑ re lacesC ❑ previously fled claim,dated288.6n <br /> amends <br /> This form is appropriatey*-forclaims relating <br /> to dealings with Breuners before October 6, 4. CLASSIFICATION OF CLAIM.Under the Bankruptcy Code all claims are classified as one or more of the <br /> 1993.If not resolved in th8 ordinary course of following:(1)Unsecured nonprioriry.(2)Unsecured priority.(3)Secured,It Is possible for part of a claim to <br /> business,claims relating to dealings with be In one category and part In another. <br /> Breuners Aftgr October 5, 1993 are adminis- CHECK THE APPROPRIATE BOX OR BOXES that best describe your cfalm and STATE THE AMOUNT <br /> trative expenses under 11 U.S.C.§503 and OF THE CLAIM. <br /> Payment must be requested by motion to the SECURED CLAIM <br /> court,not on this form. Attach evidence of perfection of security Interest 5 <br /> 1. BASiS FOR CLAIM: ❑Real Estate ❑ Motor vehicle ❑ Other(Describe briefly) <br /> ❑Goods sold Amount of arrearage and other charges included in secured claim above, <br /> ❑Services performed If any <br /> ❑Retiree benefits as defined In 5 <br /> 11 U.S.C.§1114(a) ❑ UNSECURED PRIORITY CLAIM <br /> ❑Money loaned 5 <br /> Specify the priority of the claim, i <br /> ❑ Personal Injuryhvrongful death ❑ Wages,salaries,or commissions(up to$2000),earned not more <br /> ❑Taxes than 90 days before filing of the bankruptcy petition or cessation of <br /> ❑Other(Describe briefly) the debtors business,whichever is earlier)-11 U.S.C.§507(a)(3) <br /> ❑Wages,salaries,and compensation ❑Contributions to an employee benefit plan -11 U.S.C.§507(a)(4) <br /> (Fill out below) ❑Up to$900 of deposits toward purchase,lease,or rental of property or <br /> Your social security number services for personal,family,or household use-i i U.S.C.§507(a)(6) <br /> E3 Taxes or penalties of governmental units-11 U.S.C.§507(a)(7) <br /> Unpaid compensation for services performed ❑Other-11 U.S.C.§§507(a)(2),(a)(5)-(Describe briefly) <br /> ❑ UNSECURED NONPRIORITY CLAIM $ <br /> from to A claim Is unsecured if there is no collateral or)len on property of the debtor <br /> (da[e) (date) swcuring th-clalm or to the extent that the value of such property is less than <br /> the amount at the claim. <br /> 2. DATE DEBT WAS INCURRED: S. TOTAL AMOUNT OF CLAIM AS OF OCTOBER 5,1993 <br /> ❑Check this box If claim Includes prepetition charges In addition to the principal <br /> [purpose <br /> F COURT JUDGMENT,DATE OBTAINED: amount of the claim.Attach Itemized statement of all additional charges. <br /> 5 <br /> REDITS AND SETOFFS: The amount of all payments of this claim has been credited and deducted for the <br /> of making this proof of claim. TEAS SPACE IS FOR <br /> COURT USE ONLY <br /> UPPORTING DOCUMENTS. Attach copies or supporting documents,such as promissory notes,purchase <br /> rs,Invoices,Itemized statements of running accounts,contracts,court judgments,or evidence of security <br /> est.If the documents are not avallable,explain.if the documents are voluminous,attach a summary. <br /> ME STAMPED COPY. To receive an acknowledgment of the filing of your claim,enclose a stamped, <br /> addressed envelope. <br /> Date 'Sign and print the name and title,If any,of the creditor or other person <br /> authorized to file this claim(attach copy of power of attorney,If any) <br /> Penalty for presenting fraudulent Balm:Fine of up to$500 or Imprlsanmenl for up to 5 years,or both, t 8 tl.S.0§§152 and 3571. <br /> 'Original signature required. Send original and two (2) copies to: U.S.B.C., C/o Breuners Claims <br /> Administrator, 1300 Clay Street, Suite 300, Oakland, CA 94612 to arrive no later than January 31, 1994. <br />