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Eastern District Of California (Sacramento) In re(Name of Debtor) Case Number 96-22902-5-11 East-West Healthcare LLC Cred.id: NOTE:This form should not be used to make a claim for an administrative expense arising after the commencement of the case.A"request"for payment of.an administrative expense may be filed pursuant to 11 U.S.C.4 503. Name of Creditor ❑ Check box if you are aware that (The person or other entity to whom the debtor owes money or property) anyone else has filed a proof of Y claim relating to your claim. Attach Name and Address Where Notices Should be Sent copy of statement giving particulars. ❑ Check box if you have never received any notices from the bankruptcy court in this case. ❑ Check box if the address differs from the address on the envelope THIS SPACE IS FOR Telephone No. sent to you by the court. COURT USE ONLY ACCOUNT OR OTHER NUMBER BY WHICH CREDITOR IDENTIFIES DEBTOR Check here if this claim ®replaces a previously filed claim,dated: D amends 1.BASIS FOR CLAIM ❑ Goods sold D Retiree benefits as defined in 11 U.S.C.3 1114(x) D Services performed D Wages,salaries,and compensation(Fill out below) ❑ Money loaned Your social security number ❑ Personal injury/wrongful death Unpaid compensation for services performed ❑ Taxes from t0 (date) (date) ❑ Other(Describe briefly) 2. DATE DEBT WAS INCURRED 3. IF COURT JUDGMENT,DATE OBTAINED: 4. CLASSIFICATION OF CLAIM.Under the Bankruptcy Code all claims are classified as one or more of the following:(1)Unsecured nonpriority, (2)Unsecured Priority,(3)Secured.It is possible for part of a claim to be in one category and part in another. CHECK THE APPROPRIATE BOX OR BOXES that best describe your claim and STATE THE AMOUNT OF THE CLAIM AT TIME CASE FILED. ❑SECURED CLAIM$ Specify the priority of the claim. Attach evidence of perfection of security interest ❑Wages,salaries,or commissions(up to$4000),°earned not more than Brief Description of Collateral: 90 days before filing of the bankruptcy petition or cessation of the debtor's ❑Real Estate ❑Motor Vehicle ❑Other(Describe briefly) business,whichever is earlier-11 U.S.C.¢507(x)(3) ❑Contributions to an employee benefit plan-11 U.S.C.4 507(a)(4) Amount of arrearage and othgr charges at time case filed included in secured ❑Up to$1,800"of deposits toward purchase,lease,or rental of property or claim above,if any$ services for personal,family,or household use-11 U.S.C.3(507)(a)(6) ❑UNSECURED NONPRIORITY CLAIM$ ❑Alimony,maintenance,or support owed to a spouse,former spouse,or child- 11 U.S.C.4 507(a)(7) A claim is unsecured if there is no collateral or lien on property of the ❑Taxes or penalties of governmental units-11 U.S.C.¢507(a)(8) debtor securing the claim or to the extent that the value of such property is less than the amount of the claim. ❑Other—Specify applicable paragraph of 11 U.S.C.4 507(a) 'Amounts are subject to adjustment on 4/1/98 and every 3 years thereafter with ❑UNSECURED PRIORITY CLAIM$ respect to cases commenced on or after date of adjustment. 5. TOTAL AMOUNT OF CLAIM AT TIME $ $ $ Priont $ (Total) (Unsecured) (Secured) ( Y) CASE FILED: ❑ Check this box if claim includes charges in addition to the principal amount of the claim.Attach itemized statement of all additional Charges. 6.CREDITS AND SETOFFS:The amount of all payments on this claim has been credited and deducted for the purpose THIS SPACE IS FOR of making this proof of claim.In filing this claim,claimant has deducted all amounts that claimant owes to debtor. COURT USE ONLY 7.SUPPORTING DOCUMENTS: Macti cosuch as promissory notes,purchase orders, invoices,itemized statements of running accounts,contracts,court judgments,or evidence of security interests.If the documents are not available,explain. If the documents are voluminous,attach a summary. 8.TIME-STAMPED COPY:To receive an acknowledgement of the filing of your claim,enclose a stamped,self-addressed envelope and copy of this proof of claim. Date Sign and print the name and title,if any,of the creditor or other person authorized to file this claim(attach copy of power of attorney,if any) Penalty for presenting fraudulent claim:Fine of up to$500,000 or imprisonment for up to 5 years, or both. 18 U.S.C.H 152 and 3571. 42tnns6rG