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• FORM B10((ficial Form 10)(4/01) f WED UNITED STATES BANKRUPTCY COURTnn PRR nn�g7n F CLAIM EASTERN DISTRICT OF CALIFORNIA(SACRAMENTO) CT IR Name of Debtor Case Number R.Lawson Enterprises01-29901-B-11 OFHCEI IFEMERGE.ND SERVICE:. - 'this form should not a use oma e a c atm or an a mtmstrat[ve expense ansng er RIGI�`1,.,A1. the commencement of the case. A "request" for payment of an administrative expense may be led pursuant to 11 U.S.C.§503 Name of Creditor(Che person or other entity to whom the debtor E3 Check box if you are aware that OCT. I O 2101 owes money or property): anyone else has filed a proof of Office of Emergency Services claim relating to your claim. An Name and Address where notices should be sent: copy of statement giving particul s Uh'.CG Ito �G f/,lfC?R!A ❑ Check box if you have never ORim of Emergency Services t San Joaquin County received any notices from the -- 222 EAST WEBER AVE, Room 610 bankmptcy court in this case. S-I'OCKTON CA 95202 ❑ Check box if the address differs THIS SPACE is FOR COURT USE ONLY from the address on the envelope sent to you by the court. Telephone Number: (2O9) 468-3969 Acccuur or other number by which coeditor ideadfies debtor. 9798 Check here if replaces this claim ❑amends a previously filed claim,dazed 1. Basisfor Claim ❑ Retiree benefits as defined in 11 U.S.C.§1114(a) ❑ Goods sold ❑ Wages,salaries,and compensation(fill out below) ❑ Services performed Your SS#: ❑ Money loaned Unpaid compensation for services performed ❑ Personal injury/wrongful death from to ❑ Taxes (date) (date) 0 Other Annual HaZando_us MatPrialS M 2.Date debt was incurred: 06/07/2001 3.If court judgment,date obtained: 4.Total Amount of Claim at Time Case Filed: $ Tti3 nn If all or part of your claim is secured or entitled to priority, also complete Item 5 or 6 below. ❑ Check this box if claim includes interest or other charges in addition to the principal amount of the claim. Attach itemized statement of all interest or additional charges. 5.Secured Claim. 6.Unsecured Priority Claim. ❑ Check this box if your claim is secured by collateral ❑Check this box if you have an unsecured priority claim (including a right of setoff). Amount entitled to priority$ Brief Description of Collateral: Specify the priority of the claim: ❑ Real Estate []Motor Vehicle ❑Wages,salaries,or commissions(up to$4,650)"earned within 90 days ❑ Other before filing of the bankruptcy petition or cessation of the debtor's business,whichever is earlier- 11 U.S.C.§507(a)(3). Value of Collateral: $ ❑Contributions to an employee benefit plan- 11 U.S.C.§507(x)(4). ❑Up to S 2,100*of deposits toward purchase,lease,or rental of pmperly or services for personal,family,or household use- 11 U.S.C.§507(a)(6). ❑Alimony,maintenance,or support owed to a spouse,former spouse,or child- 1 I U.S.C.§507(a)(7). Amount of arrearage and other charges at time case filed ❑Taxes or penalties owed to governmental units - 11 U.S.C.§507(a)(S). included in secured claim,if any:$ ❑Other-Specify applicable paragraph of 11 U.S.C.§507(x)(_). *Amounts are subject to adjustment on 411A4 and every 3 years thereafter with respect to cases commenced an or after the date of adjustment. 7.Credits: The amount of all payments on this claim has been credited and deducted for the purpose of PACE IS FOR OfIRT making this proof of claim. S. Supporting Documents: Attach copies of supporting documents, such as promissory notes, purchase orders, invoices, itemized statements of running accounts, contracts, court judgments, mortgages, security agreements, and evidence of perfection of lien. DO NOT SEND ORIGINAL DOCUMENTS. If the documents are not available, explain. If the documents are voluminous, attach a summary. 9.Date-Stamped Copy:To receive an acknowledgment of the filing of your claim, enclose a stamped, self- addressed envelope and copy of this proof of claim. Date Sign and print the name e,if any, at the creditor or other person authorized to file 10/08/01 . [his claim(attachc of attorney,ifany)ASS1Stdnt OOOYdIndtOP, Dennis L. Fields Haz Penalty for presenting fraudulent claim:Fine of up to$500,000 or imprisonme Strog Y'p am5 years,or both. 18 U.S.C.§§ 152 and 3571. IVKNIU �