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1J I: Pnited C;$tates +gankruptq Tourt '1;,93312—Z7 3 THE 'STE iv _I:STn1CT OF CAL IF=L:.Il" t^ IN RE: -i_401L7 Z ALICZ NA4A7 [NEZ Io JL Ri°/cTCN SLAY CASE NU:M6c;Z 90-93312 ' M07=ST10i PROOF OF CLAIM 1. This proof is made for the claimant named below by the undersigned individual who states that: (check appropriate box) The claimant is a Corporation and the Under The claimant is a partnership and He or she is agent or attorney He or she is the signed Is an authorized officer of such Corpora- the undersigned is a memberfor the claimant Claimant tion Ll thereof Ll (INDICATE THE STATE OF INCORPORATION.NAME OF PARTNERS,OR SUCH OTHER DESCRIPTION OF THE CLAIMANTAS MAY BEsupply(or verily)your account number for this debtor) 2. The undersigned represents that he or she is duly authorized to make this proof of Claim' - (if appropriate,and to accept the plan)on behalf of the claimant. I�� 3. The correct post office address of the claimant to which a6 notices and distribution Checks 5093312 — 27 —3 SAN should be mailed is stated below. SAN JCA 0U I N COUNTY PUaL.IC HEALTH P 0 5liX 2009 STCCKTJN9 CA.: 95201 If name or address, as printed, is not correct please Indicate correc 6. This claim is based upon:(check appropriate box) name and adtlress to which checks and notices should be deliverec PA 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. PRINCIPAL $1, 504 . 00 AMOUNT 5. No judgment has been rendered upon the claim,except Penalties None ADDITIONAL 600 . 00 CHARGES 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 lull credit for all payments,set-offs,and counterclaims as follows: Attached TOTAL $2 , 104 . 00 LESS PAYMENTS/ 1 (Itemize all charges in addition to principal amount of debt, state basis for inclusion and computation, AND CREDITS Il\ 00 . 00 J and set forth any other consideration relevant to the legality of any charge.) Exclude any interest ON ACCOUNT accrued alter the date the case was commenced. PRESENT PRINCIPAL Q , MDUE 2104 . DO 7. This claim Is e from any charge forbidden by applicable low end excludes all unmatured Interest (PAYOFF 0 BALANCE) 6. 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 A hereof for 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 Ilen(secured portion of claim)Is ................................ $ N A i PLAN P C•POSES P.LY.M_iiTS TO THE Ti-:USTcE OF :oIe573.00 MONTiiLY U'°4SECURED CREOITORS TO 0t PAID NGTHL-NG TT-. TS CLa.IM IS LI :.STED AS UNSECUAr D R:JU? o DATED: 9093312 27— —3 L SIGNED j vl =1LE U.S. 3ANKRUPTCY COURT (NAME OF INDIVIDUAL.AGENT,OFFICER,OR PARTNER SIGNING THIS CLAIM) CLAIM)se—sa 3--)- 5376 {{AA ,,,, / WITH: T. G — • ^/II� Penally For Presenting Fraudulent Claim CA 95352 \� Off not more than$5000 or impnsonment for not more than L 5 years or both--Title 16.U.S,C_§152