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Indlvidual, Joint, Corporacion, • <br /> partnersh(p, firm or Agcn,y <br /> (Name of Bank/Financlel institution erd Location <br /> Claim Ho. <br /> PROOF OF CLAIM SSH/Tax ID a <br /> The undersigned <br /> (yaMe of Person mitintg the Claim) a now in Liquidation (s Ju <br /> states that the <br /> (Name of 8ank/f{nand■L Inud tvtf on) in the e- <br /> Indebted to <br /> ([,rd ivldwlN(It n[/Corpontl on/Parttxrch I p/F I rm/Agrlay) <br /> dollars Mott the following claim: <br /> Account Type Liability Hutber Uninsured Principal Llablllty Number Hainsured Intere <br /> D <br /> E <br /> P <br /> O <br /> S <br /> 1 <br /> T <br /> S <br /> Total P L I <br /> Liability Ntatber Amount of Claim <br /> Descrfptfon of (Intvoice) Claim: <br /> C <br /> L <br /> ti <br /> 1 <br /> M Tocol Claim: <br /> S <br /> Undersigned further states that he/she mites this CLAIM 9n behalf of <br /> and that no part of said debt has been paid, that <br /> (Indlv(tWal/Joint/CoryoretloMPerinership/Flrm/Agency) <br /> has given no endorsement or assignment of the same or any part thereof and that there is tlo set-off or counterclalm, or ott <br /> legal or equitable defense to said claim or any oart thereof. <br /> NAME (Title) <br /> (Signature of Person making the Claim) <br /> FIRM <br /> (If applicable) <br /> ADDRESS <br /> CITY/STATE/ZIP <br /> before <br /> Sworn to and subscribed by <br /> (Name of Person signing) <br /> da of 19� <br /> Elti s Y <br /> ny Commission Expires: <br /> (Signature of officer Adni nisterin9 Oath) <br />