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nited tater �Vankruptcg Court go,3312—Z7 3 i!1 sr ii � THE ETr:f2N L::.",TF:ILT Ur CfiLiFUF• _... INRE: ' - "i.S-.iii i, ALICE P'a.k'. V-;F1 . it-.01 CRUYETLIN a:RY r, CA!4E ,4dMb0k 1+IGOL Uir 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 UnderThe 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 member❑ for the claimant Claimant 11 tion thereof (INDICATE THE STATE OF INCORPORA TION,NAME OF PARTNERS,OR SUCH OTHER DESCRIPTION OF THE CLAIMANT AS MAY BE APPROPRIA TE) (Plea&supply or wdfy)your socounl 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. 3. The correct post office address of the claimant to which all notices and distribution checksa LZ —3 should be mailed is stated below. SAN JO A C U I+II CS_*0 Y - RWiLIL HEALTH P ;1 1, x ,t q'Z 9 ST0tKT0go CA `7W01' If name or edtlress, as printed, is not correct please indicate correc 4. This claim is based upon:(check appropriate box) name end edtlress to wh'ch cheeks end notices should be tlellvered. A note, contract, or other writing. The original or complete duplicate copies of all documents are attached. (or aro 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 AMOUNT S. No judgment has been rendered upon the claim,except ADDITIONAL CHARGES 6. The debtor was at the time of the filing of the petition Initiating the can,and still is,Indebted(or liable) to this claimant(after giving full credit for all payments,set-offs,and counterclaims)as follows: TOTAL LESS AYMTSc 1 (Itemize all charges in addition to principal amount of debt, state basis for inclusion and computation, AND CREDITS J and set forth any other consideration relevant to the legality of any charge.) Exclude any interest ON ACCOUNT accrued after the date the Case was commenced. PRESENT PRINCIPAL AMOUNT DUE 7. This claim Is Iras Irom any charge forbidden by applicable law and excludes all unmetured Interest. (PAYOFF BALANCE) B. 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: (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 fair market value o1 the properly on which the claimant has a lien(secured portion of claim)Is ................................ Fp fii=1"i74LY . :5 .. _ L tL i LLt I n Y • :r l �)`•r DATED: '4693312 27— —1 SIGNED FILENAME OF INDIVIDUAL.AGENT.OFFICER,OR PARTNER SIGNING THIS CLAIMI CLAIM%,as. -.Wl KRUPTCY CJIJkT Penalty For Presenting Fraudulent Claim ;.� .,TO CA 95N!)4 • F*f not more than$5000 or imprisonment for not more than 13. (2-931 .FILE IN DUPLICATE 5 years or both--Tine 16,US.C_g 152