2025-05-12 Notice of Deadlines to File Claims against DebtorCase 24-11647-MEW Doc 472-1 Filed 05/12/25 Page 2 of 9
IN THE UNITED STATES BANKRUPTCY COURT
FOR THE DISTRICT OF DELAWARE
In re:
SILVERROCK DEVELOPMENT COMPANY,
LLC,
Debtors. I
Chapter 11
Case No.: 24-11647 (MFW)
(Jointly Administered)
NOTICE OF DEADLINES AND PROCEDURES FOR FILING PROOFS OF CLAIM
AND ADMINISTRATIVE CLAIMS AGAINST THE DEBTORS
PLEASE TAKE NOTICE THAT the above -captioned debtors and debtors -in -
possession (each, a "Debtor" and collectively, the "Debtors") each filed voluntary petitions for
relief under chapter 11 of title 11 of the United States Code, as amended (the "Bankruptcy Code")
in the United States Bankruptcy Court for the District of Delaware (the "Court") on August 5,
2024 (the "Petition Date").
PLEASE TAKE FURTHER NOTICE THAT on April 24, 2025, the Debtors filed the
Debtors ' Motion for Entry of an Order (I) Establishing Bar Dates and Related Procedures for
Filing Proofs of Claim, Including 503(b)(9) Claims, and Requests for Payment of
Administrative Expenses; (II) Approving the Form and Manner of Notice Thereof and (III)
Granting Related Relief [Docket No. 455] (the "Bar Date Motion"). On May _, 2025, the
Court entered an order approving the Bar Date Motion [Docket No. [•]] (the "Bar Date Order")
and establishing certain dates (collectively, the "Bar Dates" and each, individually, a "Bar Date")
by which parties holding claims against the Debtors must file proofs of claim or requests for
payment of administrative expenses (as applicable). Each of the Bar Dates is expressly set forth
below.
YOU ARE RECEIVING THIS NOTICE BECAUSE YOU MAY BE
HOLDING A CLAIM AGAINST THE DEBTORS IN THE ABOVE -CAPTIONED
CHAPTER 11 CASES. THEREFORE, YOU SHOULD READ THIS NOTICE
CAREFULLY AND DISCUSS IT WITH YOUR ATTORNEY. IF YOU DO NOT HAVE
AN ATTORNEY, YOU MAY WISH TO CONSULT ONE.
The Debtors in these chapter 11 cases, along with the last four digits of each Debtor's federal tax identification
number, as applicable, are: SilverRock Development Company, LLC (5730), RGC PA 789, LLC (5996),
SilverRock Lifestyle Residences, LLC (0721), SilverRock Lodging, LLC (4493), SilverRock Luxury Residences,
LLC (6598) and SilverRock Phase I, LLC (2247). The location of the Debtors' principal place of business and
the Debtors' mailing address is 343 Fourth Avenue, San Diego, CA 92101.
Case 24-11647-MFW Doc 472-1 Filed 05/12/25 Page 3 of 9
ACCESS TO CLAIM FORMS AND ADDITIONAL INFORMATION
Proofs of claim are to be filed using Official Form 410 (the "Claim Form") or in a form that
is substantially similar. Requests for payment of administrative expenses must be made by motion.
If you have any questions regarding the claims process and/or if you wish to obtain a copy of the Bar
Date Motion, the Bar Date Order (which contains a more detailed description of the requirements
for filing proofs of claim), a Claim Form, or related documents including the Schedules and
Statements (as defined below)), you may do so by contacting the Debtors' proposed claims agent,
Reliable Companies ("Reliable" or the "Claims Agent") or proposed co -counsel to the Debtors,
Wilson Sonsini Goodrich & Rosati, P.C., Attn: Shane M. Reil and Catherine C. Lyons (emails:
sreil@wsgr.com and clyons@wsgr.com).
SCHEDULES OF ASSETS AND LIABILITIES
The Debtors filed their schedules of assets and liabilities and statements of financial affairs
[Docket Nos. 114-119] with the Court on September 18, 2024 (as amended or modified, the
"Schedules and Statements"). Certain of the Schedules and Statements were amended on September
27, 2024. See Docket No. 153. The Debtors' Schedules and Statements and the Bar Date Order may
be examined and inspected by interested parties during posted hours at the Clerk of the Bankruptcy
Court, United States Bankruptcy Court for the District of Delaware, 824 North Market Street, 3rd
Floor, Wilmington, Delaware 19801 and are also available free of charge by visiting the website for
these chapter 11 cases maintained by Reliable: https://www.bankruptcy-claims.com/silverrock.
BAR DATES APPROVED BY THE COURT
The Court has established the following Bar Dates as those dates by which parties holding
Claims against the Debtors must file proofs of claim so that they are actually received by the
Claims Agent:
a. June 16, 2025 at 5:00 p.m. (Eastern Time) is the deadline for each person or
entity (including individuals, partnerships, corporations, joint ventures, trusts,
but not including governmental units (as defined in section 101(27) of the
Bankruptcy Code) ("Governmental Units")), to file a proof of claim (each, a
"Proof of Claim") in respect of a prepetition claim (as defined in section 101(5)
of the Bankruptcy Code), including, for the avoidance of doubt, secured claims,
unsecured priority claims, unsecured non -priority claims, and claims arising
under section 503(b)(9) of the Bankruptcy Code,'- against the Debtors (the
"General Bar Date"), unless otherwise provided herein;
b. June 16, 2025 at 5:00 p.m. (Eastern Time) is the deadline for Governmental
Units to file a Proof of Claim in respect of a prepetition claim against the
Debtors (the "Governmental Bar Date");
Claims arising under section 503(b)(9) of the Bankruptcy Code are a type of administrative expense claim in
bankruptcy law, specifically for goods delivered to the Debtors within twenty (20) days before the Petition Date,
provided such goods were sold to the Debtors in the ordinary course of their business.
2
Case 24-11647-MFW Doc 472-1 Filed 05/12/25 Page 4 of 9
c. June 16, 2025 at 5:00 p.m. (Eastern Time) (the "Administrative Claims Bar
Date") is the deadline for each person or entity that asserts a request for payment
of administrative claims arising between the Petition Date and the date of entry
of the Bar Date Order (the "Administrative Claims Period"), excluding (i)
claims for professional fees and expenses in these chapter 11 cases, and (ii)
claims asserting administrative priority and arising in the ordinary course of
business after the Petition Date (the "Administrative Claims"), to file a motion
for payment of such Administrative Claims;
d. the later of (i) the General Bar Date or the Governmental Bar Date, as
applicable, or (ii) 5:00 p.m. (prevailing Eastern Time) on the date that is 30 days
from the date on which the Debtors provide notice of a previously unfiled
Schedule or Statement or an amendment or supplement to the Schedules and
Statements (as defined herein) is the deadline by which claimants holding
claims affected by such filing, amendment or supplement must file Proofs of
Claim with respect to such claim (the "Amended Schedules and Statements Bar
Date");
e. the later of (i) the General Bar Date or the Governmental Bar Date, as
applicable, or (ii) 5:00 p.m. (prevailing Eastern Time) on the date that is 30
days following service of an order approving the rejection of any executory
contract or unexpired lease of the Debtors is the deadline by which claimants
asserting claims resulting from any such rejection must file Proofs of Claim
for damages arising therefrom (the "Rejection Damages Bar Date," and,
together with the General Bar Date, the Governmental Bar Date, the
Administrative Claims Bar Date, the Amended Schedules and Statements Bar
Date, and any Special Bar Dates (as defined in the Bar Date Order), the "Bar
Dates").
PARTIES REQUIRED TO FILE PROOFS OF CLAIM
Parties Who Must File Claims and/or Motions for Payment of Administrative Claims.
Except as otherwise set forth herein, the following entities holding claims against the Debtors
arising prior to the Petition Date are required to file Proofs of Claim or motions for payment of
Administrative Claims arising during the Administrative Claims Period (as applicable) on or
before the applicable Bar Date:
a. any entity whose claim against the Debtors is not listed in the applicable
Schedules and Statements, or is listed as "contingent, '`unliquidated," or
"disputed";
b. any entity that believes that its claim is improperly classified in the Schedules
and Statements3 or is listed in an incorrect amount and who desires to have its
The Schedules and Statements can be found at Docket Nos. 114-119. An amended Schedule D for SilverRock
Development Company LLC can be found at Docket No.153. The Schedules and Statements may also he viewed
at Reliable's website for these chapter 11 cases: https://www.bankruptcy-claims.com/sil\ crrock.
3
Case 24-11647-MFW Doc 472-1 Filed 05/12/25 Page 5 of 9
claim allowed in a different classification or amount other than that identified
in the Schedules and Statements;
c. any entity that believes that its claim against the Debtors is or may be an
Administrative Claim that arises during the Administrative Claims Period,
excluding (i) claims for professional fees and expenses in these chapter 11
cases, and (ii) claims asserting administrative priority and arising in the
ordinary course of business after the Petition Date; and
d. any entity who believes that its claim against the Debtors is or may be entitled
to priority under section 503(b)(9) of the Bankruptcy Code (i.e., a claim for the
value of goods received by the Debtors within 20 days before the Petition Date
in which the goods have been sold to the Debtors in the ordinary course of the
Debtors' business).
Parties Who Do Not Need To File Proofs of Claim or Motions for Payment of
Administrative Claims. The following entities whose claims would otherwise be subject to a Bar
Date are not required to file any Proofs of Claim or motions for payment of Administrative Claims
at this time solely with respect to such claim:
a. any person or entity whose claim is listed on the Schedules and Statements;
provided that (i) the claim is not listed on the Schedules and Statements as
"disputed," "contingent," or "unliquidated," and (ii) the person or entity does
not dispute the amount, nature, and priority of the claim as set forth in the
Schedules and Statements;
b. any person or entity who already has filed a signed Proof of Claim with the
Court against the Debtors with respect to the claim being asserted, utilizing a
claim form that substantially conforms to the Claim Form;
c. any person or entity who holds a claim that has been allowed by order of the
Court entered on or before the applicable Bar Date;
d. any person or entity whose claim has been paid in full;
e. any person or entity who holds a claim for which a separate deadline has been
fixed by an order of the Court entered on or before the applicable Bar Date;
f. any person or entity who holds an equity interest in the Debtors, which interest
exclusively is based upon the ownership of common or preferred stock,
membership interests, partnership interests, or warrants, options, or rights to
purchase, sell, or subscribe to such a security or interest; provided that if any
such holder asserts a claim (as opposed to an ownership interest) against the
Debtors (including a claim relating to an equity interest or the purchase or sale
of such equity interest), a Proof of Claim or a motion for payment of an
Administrative Claim, as applicable, must be filed on or before the applicable
Bar Date pursuant to the procedures set for the herein;
any person who is serving as an officer, director, or employee of the Debtors as
of the date of the filing of the Bar Date Motion, for claims based on
indemnification, contribution, or reimbursement;
g.
4
Case 24-11647-MFW Doc 472-1 Filed 05/12/25 Page 6 of 9
h. any entity whose claim is solely against any of the Debtorsnon-Debtor
affiliates;
i. any person or entity that has an Administrative Claim for professional fees and
expenses for which (i) such person or entity has been retained by an express
order of the Court pursuant to section 327, 328, 363 or 1103 of the Bankruptcy
Code, and (ii) such person or entity is seeking compensation for such services
through filed monthly fee statements and applications in accordance with the
Interim Compensation Order4or through similar reporting mechanisms.
j. any holder of a claim allowable under section 503(b) and 507(a)(2) of the
Bankruptcy Code as an administrative expense that arose on or after May 15,
2025; and
k. any claims held by the City of La Quinta, California (the "City"), including,
without limitation, any claims of the City in its capacity as the DIP Lender or
arising under the DIP Loan Documents.5
INSTRUCTIONS FOR FILING PROOFS OF CLAIM
a. Proofs of Claim must substantially conform to the Official Bankruptcy Form
No. 410 or to the version of the Proof of Claim Form made available by the
Debtors on the website for these chapter 11 cases at https://www.bankruptcy-
claims.comisilverrock;
b. Proofs of Claim must: (i) be written in the English language; (ii) be
denominated in lawful currency of the United States as of the Petition Date
(using the exchange rate, if applicable, as of the Petition Date); (iii) specify by
name and case number the Debtor against which the claim is filed; (iv) set forth
with specificity the legal and factual basis for the alleged claim; (v) include
supporting documentation for the claim or an explanation as to why such
documentation is not available; and (vi) be signed by the claimant or, if the
claimant is not an individual, by an authorized agent of the claimant under
penalty of perjury;
c. Requests for payment of Administrative Claims must be filed by motion
pursuant to 11 U.S.C. § 503;
d. Proofs of Claim must be filed (i) electronically through the website of the
Debtors' claims and noticing agent, Reliable Companies ("Reliable") at
https://www.bankruptcy-claims.com/silverrock (the "Electronic Filing
System") or (ii) by delivering the original Proof of Claim form by hand, or
See Order. Pursuant to Sections l05(a) and 33/ of the Bankruptcy Code, Bankruptcy Rule 2016(a). and Local
Rule 20/6-2. Estahlishing Procedures for Interim Compensation and Reimbursement of Professionals [Docket
No. 108].
Capitalized terms used but not defined in this subsection (k) have the meanings ascribed to such terms in the Final
Order (FINAL) (I) .Authorizing the Debtors to Obtain Postpetition Secured Financing. (II) Granting Priming
Liens and Superprwritr Administrative Expense Status. and (III) Granting Related Relief [Docket No. 330].
Moreover, to the e.tent that an additional bar date is set with respect to any claims held by the City, such bar date
shall be set via convent with the City or through the establishment of a special bar date.
5
Case 24-11647-MFW Doc 472-1 Filed 05/12/25 Page 7 of 9
mailing the original Proof of Claim form on or before the applicable Bar Date
as follows:
If sent by mail, send to:
Reliable Companies
Attn: Gene Matthews
1007 North Orange Street, Suite 110
Wilmington, DE 19801
e. A Proof of Claim shall be deemed timely filed only if it actually is received by
Reliable, as set forth in subparagraph (d) above, in each case, on or before the
applicable Bar Date; and
f. Proofs of Claim sent by facsimile, telecopy, or electronic mail transmission
(other than Proofs of Claim filed electronically through the Electronic Filing
System) will not be accepted.
Claimants wishing to receive acknowledgment that their Proof of Claim was
received by the Court must submit (i) a copy of the Proof of Claim (in addition
to the original Proof of Claim sent to the Court); and (ii) a self-addressed,
stamped envelope.
g.
EXCEPT AS EXPRESSLY PERMITTED ABOVE, A PROOF OF CLAIM FORM
OTHERWISE SUBMITTED BY FACSIMILE, TELECOPY, ELECTRONIC MAIL OR
OTHER FORM OF ELECTRONIC SUBMISSION WILL NOT BE ACCEPTED.
Receipt of Service. Holders of claims wishing to receive acknowledgment that their
Proofs of Claim were received by the Claims Agent must submit (i) a copy of the Proof of Claim
and (ii) a self-addressed, stamped envelope.
CONSEQUENCES OF FAILING TO TIMELY FILE YOUR CLAIM
UNLESS THE COURT ORDERS OTHERWISE, PURSUANT TO BANKRUPTCY
RULE 3003(c)(2), ANY HOLDER OF A CLAIM WHO IS REQUIRED TO TIMELY FILE
A PROOF OF CLAIM OR A MOTION FOR AN ADMINISTRATIVE CLAIM ON OR
BEFORE THE APPLICABLE BAR DATE AS PROVIDED HEREIN, BUT FAILS TO DO
SO, (I) SHALL NOT BE TREATED AS A CRDITOR FOR THE PURPOSES OF VOTING
ON A CHAPTER 11 PLAN AND DISTRIBUTION IN THESE CHAPTER 11 CASES ON
ACCOUNT OF SUCH CLAIM OR ADMINISTRATIVE CLAIM; AND (II) SHALL BE
FOREVER BARRED, ESTOPPED, AND ENJOINED FROM ASSERTING SUCH CLAIM
OR ADMINISTRATIVE CLAIM AGAINST THE DEBTORS AND THEIR PROPERTY
(OR FILING A PROOF OF CLAIM OR ADMINISTRATIVE CLAIM WITH RESPECT
THERETO).
AMENDMENTS TO THE DEBTORS' SCHEDULES AND STATEMENTS
1. Amendments to Schedules and Statements. In the event the Debtors amend their
Schedules and Statements after the date of this notice, the Debtors will provide holders of
claims that are affected by the amendment notice of the amendment, and such parties will
6
• Case 24-11647-MFW Doc 472-1 Filed 05/12/25 Page 8 of 9
be given an opportunity to file Proofs of Claim or to amend any previously filed claim
before a new deadline that will be specified in that future notice.
2. Amended Schedules and Statements Bar Date. The Court has approved the later of (i)
the General Bar Date or the Governmental Bar Date, as applicable, or (ii) 5:00 p.m.
(prevailing Eastern Time) on the date that is 30 days from the date on which an affected
claimant receives notice of a previously unified Schedule or Statement or an amendment
or supplement to the Schedules and Statements (as defined herein) as the deadline by which
claimants holding claims affected by such filing, amendment or supplement must file
Proofs of Claim with respect to such claim (the "Amended Schedules and Statements Bar
Date").
PARTIES TO THE DEBTORS' LEASES AND EXECUTORY CONTRACTS
1. Rejection of Leases and Contracts. The Bankruptcy Code provides that the Debtors may,
at any time before a plan is confirmed by the Court, choose to reject certain executory
contracts or unexpired leases. If your contract or lease is rejected, you may have a claim
resulting from that rejection.
2. Proofs of Claim Relating to Rejection Damages. The deadline to file a proof of claim for
damages relating to the rejection of an executory contract or unexpired lease is the later of
(i) the General Bar Date or the Governmental Bar Date, as applicable, or (ii) 5:00 p.m.
(prevailing Eastern Time) on the date that is 30 days following receipt by an affected
claimant of an order approving rejection of any such executory contract or unexpired lease
(the "Rejection Damages Bar Date").
RESERVATION OF RIGHTS
Nothing contained in this notice is intended to or should be construed as a waiver of the
Debtors' or any successors' rights to: (a) dispute, or assert offsets or defenses against, any filed
claim or any claim listed or reflected in the Schedules and Statements as to the nature, amount,
liability, classification, characterization or validity thereof; (b) subsequently designate any
scheduled claim as disputed, contingent or unliquidated; and (c) otherwise amend or supplement
the Schedules and Statements.
If you have any questions relating to this Notice, please contact proposed co -counsel for the
Debtors at the contact in formation below.
THE DEBTORS ARE NOT AUTHORIZED TO PROVIDE YOU WITH LEGAL
ADVICE.
Dated: [.], 2025 WILSON SONSINI GOODRICH &
ROSATI, P.C.
/.s/
Erin R. Fay (No. 5268)
Shane M. Reil (No. 6195)
❑ ❑I I I C❑ w ❑❑ 11100 ❑❑❑® EOM ❑❑®❑®❑ ❑❑❑❑ D ❑❑❑
Catherine C. Lyons (No. 6854)
Heather P. Lambert (No. 6923)
222 Delaware Avenue, Suite 800
Wilmington, Delaware 19801
Telephone: (302) 304-7600
Emails: efay@wsgr.com
sreil@wsgr.com
clyons@wsgr.com
hlambert@wsgr.com
Proposed Co -Counsel to the Debtors
-and-
LAW OFFICES OF BENJAMIN M.
CARSON, P.C.
Benjamin M. Carson (admitted pro hac vice)
5965 Village Way, Suite E105
San Diego, California 92130
Telephone: (858) 255-4529
Email: ben@benjamincarson.com
-and-
Victor A. Vilaplana (admitted pro hac vice)
823 La Jolla Rancho Road
La Jolla, California 92037
Telephone: (619) 840-4130
Email: vavilaplana@gmail.com
Counsel to the Debtors
8
Fill in this information to identify the case:
Debtor 1
Debtor 2
(Spouse, if filing)
United States Bankruptcy Court for the: District of
Case number
Official Form 410
Proof of Claim
12/24
Read the instructions before filling out this form. This form is for making a claim for payment in a bankruptcy case. Do not use this form to
make a request for payment of an administrative expense. Make such a request according to 11 U.S.C. § 503.
Filers must leave out or redact information that is entitled to privacy on this form or on any attached documents. Attach redacted copies of any
documents that support the claim, such as promissory notes, purchase orders, invoices, itemized statements of running accounts, contracts, judgments,
mortgages, and security agreements. Do not send original documents; they may be destroyed after scanning. If the documents are not available,
explain in an attachment.
A person who files a fraudulent claim could be fined up to $500,000, imprisoned for up to 5 years, or both. 18 U.S.C. §§ 152, 157, and 3571.
Fill in all the information about the claim as of the date the case was filed. That date is on the notice of bankruptcy (Form 309) that you received.
Part 1:
Identify the Claim
1 Who is the current
creditor?
City of La Quinta
Name of the current creditor (the person or entity to be paid for this claim)
Other names the creditor used with the debtor
2. Has this claim been
acquired from
someone else?
13. Where should notices
and payments to the
creditor be sent?
Federal Rule of
Bankruptcy Procedure
(FRBP) 2002(g)
❑ No
❑ Yes. From whom?
Where should notices to the creditor be sent?
City of La Quinta
Name
78495 Calle Tampico
Number Street
La Quinta CA 92253
City State
Contact phone
Contact email
Uniform clam identifier (if you use one):
Where should payments to the creditor be sent? (if
different)
Name
Number Street
ZIP Code City State ZIP Code
Contact phone
Contact email
4. Does this claim amend ❑ No
one already filed? ❑ Yes. Claim number on court claims registry (if known)
5. Do you know if anyone
else has filed a proof
of claim for this claim?
❑ No
❑ Yes. Who made the earlier filing?
Filed on
MM / DID / YYYY
Official Form 410
Proof of Claim
page 1
Part 2:
Give Information About the Claim as of the Date the Case Was Filed
6. Do you have any number ❑ No
you use to identify the ❑ Yes. Last 4 digits of the debtor's account or any number you use to identify the debtor:
debtor?
7. How much is the claim? $ . Does this amount include interest or other charges?
❑ No
❑ Yes. Attach statement itemizing interest, fees, expenses, or other
charges required by Bankruptcy Rule 3001(c)(2)(A).
8 What is the basis of the
claim?
Examples: Goods sold, money loaned, lease, services performed, personal injury or wrongful death, or credit card.
Attach redacted copies of any documents supporting the claim required by Bankruptcy Rule 3001(c).
Limit disclosing information that is entitled to privacy, such as health care information.
9. Is all or part of the claim
secured?
10 Is this claim based on a
lease?
11 Is this claim subject to a
right of setoff?
❑ No
❑ Yes. The claim is secured by a lien on property.
Nature of property:
❑ Real estate. If the claim is secured by the debtor's principal residence, file a Mortgage Proof of Claim
Attachment (Official Form 410-A) with this Proof of Claim.
❑ Motor vehicle
❑ Other. Describe:
Basis for perfection:
Attach redacted copies of documents, if any, that show evidence of perfection of a security interest (for
example, a mortgage, lien, certificate of title, financing statement, or other document that shows the lien has
been filed or recorded.)
Value of property: $
Amount of the claim that is secured: $
Amount of the claim that is unsecured: $ (The sum of the secured and unsecured
amounts should match the amount in line 7.)
Amount necessary to cure any default as of the date of the petition: $
Annual Interest Rate (when case was filed)
❑ Fixed
❑ Variable
❑ No
❑ Yes. Amount necessary to cure any default as of the date of the petition. $
❑ No
❑ Yes. Identify the property:
Official Form 410
Proof of Claim
page 2
i 12. Is all or part of the claim
entitled to priority under
11 U.S.C. § 507(a)?
• A claim may be partly
•
• priority and partly
•
nonpriority. For example,
•
in some categories, the
•
•
law limits the amount
entitled to priority.
Part 3:
Sign Below
❑ No
❑ Yes. Check one:
❑ Domestic support obligations (including alimony and child support) under
11 U.S.C. § 507(a)(1)(A) or (a)(1)(B).
D Up to $3,350" of deposits toward purchase, lease, or rental of property or services for
personal, family, or household use. 11 U.S.C. § 507(a)(7).
Amount entitled to priority
❑ Wages, salaries, or commissions (up to $15,150*) earned within 180 days before the
bankruptcy petition is filed or the debtor's business ends, whichever is earlier. $
11 U.S.C. § 507(a)(4).
❑ Taxes or penalties owed to governmental units. 11 U.S.C. § 507(a)(8). $
❑ Contributions to an employee benefit plan. 11 U.S.C. § 507(a)(5). $
❑ Other. Specify subsection of 11 U.S.C. § 507(a)(_) that applies. $
* Amounts are subject to adjustment on 4/01/25 and every 3 years after that for cases begun on or after the date of adjustment.
The person completing
this proof of claim must
sign and date it.
FRBP 9011(b).
If you file this claim
electronically, FRBP
5005(a)(3) authorizes courts
to establish local rules
specifying what a signature
is.
A person who files a
fraudulent claim could be
fined up to $500,000,
imprisoned for up to 5
years, or both.
18 U.S.C. §§ 152, 157, and
3571.
Check the appropriate box:
❑ I am the creditor.
❑ I am the creditor's attorney or authorized agent.
❑ I am the trustee, or the debtor, or their authorized agent. Bankruptcy Rule 3004.
❑ I am a guarantor, surety, endorser, or other codebtor. Bankruptcy Rule 3005.
I understand that an authorized signature on this Proof of Claim serves as an acknowledgment that when calculating the
amount of the claim, the creditor gave the debtor credit for any payments received toward the debt.
I have examined the information in this Proof of Claim and have a reasonable belief that the information is true
and correct.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on date
MM / DD / YYYY
Signature
Print the name of the person who is completing and signing this claim:
Name
Title
Company
Address
Contact phone
First name
Middle name
Last name
Identify the corporate servicer as the company if the authorized agent is a servicer.
Number Street
City
State ZIP Code
Email
Official Form 410
Proof of Claim page 3