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1OtL� of , nited �ttttes Bankruptcq Gurt t3093312-27 3 THE 7ERiti 01 STP IC T CF C:ItL iF,_ .. IN RE: ELA010 L ALICE n.,A T INEZ 1z01 GRUVETDN WAY CASE AiUM3cR 90-93322 ' +Y0�3cs'T0. PROOF OF CLAIM 1. This proof is made for the Claimant named below by the undersigned individual who states that: (check appropriate box) ❑ He or she is the ❑ The claimant Is a Corporation and the Under The claimant is a partnership and signed is an authorized officer of such Cor ora- undersigned p p He or she is agent or attorney Claimant lion P the undersig netl is a member He the claimant thereof (INDICATE THE STA TE OF INCORPORATION.NAME OF PARTNERS,OR SUCH OTHER DESCRIPTION OF THE CLAIMANT AS MAY BE APPROPRIATE) (Plew supply(or verify)your account number for this deblor) 2. The undersigned represents that he or she is duly authorized IC make this proof of claim' (if appropriate,and to accept the plan)on behalf of the claimant. 3. The correct post office address of the claimant to which all notices and distribution checks 9093322 — 27 —3 SAN should be mailed is stated below. SAN JOAQUIN COUNTY - PUBLIC HEALTH P 0 BOX 2009 STOCKTONg CA. 95201 d. This claim is based upon:(check appropriate box) I name or address, as printed, is not correct please indicate correc name and address to which checks and notices should be defiverec A note, contract. or other writing. The original or complete duplicate copies of all documents are attached, (or are not attached for the reason set forth in the statement attached hereto). An open account.An Itemized statement showing the date due Is attached. CALCULATION OF BALANCE DUE Other consideration(or ground of liability).Explain. c ,1 PRINCIPA 5. No judgment has been rendered upon the claim,except AMOUNT L $1,504 . 00 None Penalties ADDITIONAL 600 . 00 CHARGES 6OO OO 6. The debtor was at the time of the filing of the petition initiating the case,and still Is,indebted(or liable) to this claimant(after giving full credit for all payments,set-offs,and counterclaims)as follows: Attached TOTAL $2 , 104 .00 (Itemize all charges in addition to principal amount of debt, state basis for inclusion and computation, LESS PAYMENTS AND CREDITS00 . 00 Q Q Q 1 and set forth any other consideration relevant to the legality of any charge.) Exclude any interest ONACCOUNT J accrued after the date the case was commenced. PRESENT PRINCIPAL d` 2 104 .-00 7. This elelm Is Tree from any charge forbidden itltlen by applicable law and excludes all unmalurad Interest. DUE �P r (PAYOFF BALANCE) 8. This claim is a general unsecured claim,except to the extent that the security interest,if any,described below is sufficient to satisfy the claim.(If priority is claimed,state the amounts and the basis thereof:) 9. NO SECURITY INTEREST IS HELD FOR THIS CLAIM EXCEPT: None (If security interest in property of the debtor is claimed). The security interest is claimed under the writing referred to In Paragraph 4 hereof (or under a separate writing which (or a duplicate of which) 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. 10. The lair market value of the property on which the claimant has a lien(secured portion of claim)Is ................................ $ N A T-iE PLAN PRCPJSES PAYM_NTS TO THE TRUSTEE OF S1Ir579.00 MONTHLY U14SECUREO CREDITORS TO 8t PAID NOTHING tills CLr;IM IS LISTED AS, UNSECURO _ GROUP o DATED: _ /V/ .. ......... 909-3312 27— —3 FILE UeSsi 3ANKRUPTCY COURT C SIGNED CLAIM (NAME OF INOIV,OUA4 AGENT,OFF PApiNEfl aIeNING TMIe CLAIMI ?.O. 30X 5376 wlrH:fiJOESTO CA 95352 r1 qty For Presenting Fraudulent Claim Fine of 1# than$5000 or imprisonment for not more than ...13. (2-83) FILE IN DUPLICATE 5years or both--Title 18.U.S.C.,§152