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This is a Baker Hostetler form that can be used for Securities Investor Protection Corporation.
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PROOF OF CLAIM UNITED STATES BANKRUPTCY COURT FOR THE ) SECURITIES INVESTOR PROTECTION ) CORPORATION, Plaintiff-Applicant v. Adv. Case No. Defendant. ) ) ) ) Amount of Claim $ ) ) Claimed As: [ ] General Unsecured ) [ ] Priority (see Paragraph 10) ) [ ] Secured (see Paragraph 9) ) 1. Name of Creditor (Print or Type) Mailing Address City State Zip Code 2. The debtor was, at the time of the filing of the petition initiating this case, and still is indebted (or liable) to this claimant in the sum of $ 3. The consideration for this debt (or ground of liability) is as follows: 4. (If the claim is founded on writing.) The writing on which this claim is founded (or a duplicate thereof) is attached hereto (or cannot be attached for the reason set forth in the following statement). 5. (If appropriate,) This claim is founded on an open account, which became (or will become) due on , as shown by the itemized statement attached hereto. Unless it is attached hereto or its absence is explained in an attached statement, no note or other negotiable instrument has been received for the account or any part of it. SEE REVERSE SIDE American LegalNet, Inc. www.FormsWorkflow.com PROOF OF CLAIM ) ) CLAIM NUMBER 6. No judgment has been rendered on the claim except: 7. The amount of all payments on this claim has been credited and deducted for the purpose of making this proof of claim. 8. This claim is not subject to any set-off or counterclaim except: 9. No security interest is held for this claim except: (If security interest in property of the debtor is claimed) The undersigned claims the security interest under the writing referred to in paragraph 4 hereof. Evidence of perfection of such security interest is also attached hereto. 10. This claim is an unsecured claim, except to the extent that the security interest, if any, described in paragraph 9 is sufficient to satisfy the claim. It is not entitled to priority unless the reason for priority and the amount claimed as priority is set forth below. 11. If claimant has obtained this claim by assignment, a copy or explanation of said assignment is attached hereto. 2 American LegalNet, Inc. www.FormsWorkflow.com Name of Creditor (PRINT OR TYPE) Signature. Title (Corporate Officer, Partner, or Agent) IT IS A VIOLATION OF FEDERAL LAW TO FILE A FRAUDULENT CLAIM. CONVICTION CAN RESULT IN A FINE OF NOT MORE THAN $50,000 OR IMPRISONMENT FOR NOT MORE THAN 5 YEARS OR BOTH. 3 American LegalNet, Inc. www.FormsWorkflow.com