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Individual, Joint, Corporation, 0 • <br /> Partnership, firm or Agcrxy <br /> (Name of Dank/F irurx(el Institution and Location) <br /> Claim No. <br /> PROOF OF CLAIM <br /> SSR/Tax ID a <br /> The trdersigncd <br /> (Iiame of Person asking the Claim) <br /> now in Liquidation is Ju <br /> states that the <br /> (Name of sank/Financial Ins ti tvtf on) <br /> in the a <br /> Indebted to <br /> (tldlvldual/Jalnt/Cotparac)oNPartnerchlp/Fftm/A9cncY) <br /> dollars upon the following claim: <br /> Account Typo Liability Humber Uninsured Principal i.lability Number FfntruureG Inter <br /> D <br /> E <br /> P <br /> O <br /> S <br /> I <br /> T <br /> S <br /> Total P i I <br /> Description of (iltvoice) Claim: Liability Humber Amount of Claim <br /> C <br /> L <br /> h <br /> 1 <br /> H Total Claim: <br /> S <br /> Undersigned further states that he/she makes this claim on behalf of <br /> and that no part of said debt has been paid, that <br /> (Indlvidual/Joint/Corporation/Partnership/FfrnVAgency) <br /> has given no endorsement or assignment of the same or any part thereof and that there is W set-off or counterclaim, or ott <br /> Legal or equitable defense to said claim or any cart thereof. <br /> NAME <br /> (Signature of Person making the Claim) (Title) , <br /> FIRM <br /> (If applicable) <br /> ADDRESS <br /> CITY/STATE/ZIP <br /> before <br /> Sworn to and subscribed by <br /> (Rana of Person signing) <br /> Fht� day of 19� <br /> My Commission Expires: <br /> (Signature of officer Adninisterin9 Oath) <br />