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UNITED STATES BANKRUPTCY COURT P20006862 95201 9191522 10T ERN DISTRICT OF CALIFORN� P .O. BOX 728 STOCKTON, CA 95201-0728 SSN/ID: P.O. BOX 728 STOCKTON , CA 95201-0728 68-0053182 PROOF OF CLAIM 1. This proof is made for the claimant named oelow by the undersigned individual who resides at and who also❑ AN INDIVIDUAL ares that he or 1 is A PART`ZRSHIP to make this c1 AOn behalf of CORPORATIONe claimant, which OTHER (INDICATE THE STATE OF INCORPORATION, NAME OF PARTNERS. OR SUCH OTHER DESCRIPTION OF THE CLAIMANT AS MAY BE APPROPRIATE 2. The post office address of the claimant and the address to which all notices to this claimant should be addressed is 9191522 — DEBTOR SEIBOLD CORPORATION If name or address, as printed, is not correct please P. O. B OX 728 indicate correct name and address to which checks and notices should be delivered. STOCKTON, CA 95201-0728 3. The debtor was, at the time of the filing of the petition initiating this case. and still is indebted (or liable) to this claimant, (excluding all Lamatured interest) in the sum of------------------------------- 4. The consideration for this debt for ground of liability) is as follows: S. III the claim is founded on writing) The writing on which this claim is founded for a duplicate thereof) is attached hereto for cannot be attached for the reason set forth in the statement attached hereto). 6. (If appropriate) This claim is founded on an open account which became (or will become) due on as shown by the itemized statement attached hereto. Unless it is attached hereto or its absence is explained in an attached statement, no note or other negotiable instrument has been received for the account or any part of it. 7. No judgment has been rendered on this claim except 8. The amount of all payments an this claim has been credited and deducted for the purpose of making this proof of claim. 9. This claim is not subject to any set-off or cnxatter-claim except 10. No security interest is held for this claim except If security interest in property of the debtor is claimed). The security interest is claimed under the writing referred to in Paragraph 5 hereof (or undo a separate writing which lot a dupficate of "ich) is attached hereto, or under a separate writing which cannot be attached hereto for the reason set forth in the statement attached hereto). Evidence of perfection of such security interest is also attached hereto. 11. This claim is a general unsecured claim, except to the extent that the security interest, if any, described in paragraph 10 is sufficient to satisfy the claim. (If priority is claimed, state the amakent and the basis thereof.) 12. If this claim is for salaries, wages, commissions or employee benefits entitled to priority as permitted by 4507(a)(3) andlor 5507(a)(4) of the Bankruptcy Code, indicate the dates and the nature of the services performed, SSN the rates of compensation and claimant's Social Security Number. FILE IN DUPLICATE WITH: , DATED U . S . BANKRUPTCY COURT CLAIMS DEPARTMENT P . 0. BOX 5376 MODESTO, CA 95352-5376 SIGNED (Name of individual, agent, officer or partner signing this claim) PENALTY FOR PRESENTING FRAUDULENT CLAIM / 0 FINE OF NOT MORE THAN $5000 OR IMPRISONMENT FOR NOT MORE THAN 5 FORM 15 (8183) YEARS OR BOTH --TITLE 18. U.S.C. PAR 152.