CACB — Check if this is an (401)

Source: https://www.cacb.uscourts.gov/sites/cacb/files/documents/forms/401.pdf

Fill in this information to identify the case:

United States Bankruptcy Court for the:

____________________ District of _________________ (State) Case number (If known): _________________________ Chapter 15 Check if this is an amended filing

Official Form 401 Chapter 15 Petition for Recognition of a Foreign Proceeding 12/15

If more space is needed, attach a separate sheet to this form. On the top of any additional pages, write debtor’s name and case number (if known).

_____________________________________________________________________________________________1. Debtor’s name

2. Debtor’s unique identifier For non-individual debtors:

   Federal Employer Identification Number (EIN) ___ ___ – ___ ___ ___ ___ ___ ___ ___

   Other ___________________________. Describe identifier _____________________________.

   For individual debtors:

   Social Security number: xxx – xx– ____ ____ ____ ____

   Individual Taxpayer Identification number (ITIN): 9 xx – xx – ____ ____ ____ ____

   Other ___________________________. Describe identifier ______________________________.

3. Name of foreign representative(s) ____________________________________________________________________________________________

4. Foreign proceeding in which appointment of the foreign ____________________________________________________________________________________________ representative(s) occurred

5. Nature of the foreign Check one: proceeding Foreign main proceeding Foreign nonmain proceeding Foreign main proceeding, or in the alternative foreign nonmain proceeding

6. Evidence of the foreign A certified copy, translated into English, of the decision commencing the foreign proceeding and proceeding appointing the foreign representative is attached. A certificate, translated into English, from the foreign court, affirming the existence of the foreign proceeding and of the appointment of the foreign representative, is attached. Other evidence of the existence of the foreign proceeding and of the appointment of the foreign representative is described below, and relevant documentation, translated into English, is attached. _______________________________________________________________________________________ _______________________________________________________________________________________

7. Is this the only foreign No. (Attach a statement identifying each country in which a foreign proceeding by, regarding, or against the proceeding with respect to debtor is pending.) the debtor known to the Yes foreign representative(s)?

Official Form 401 Chapter 15 Petition for Recognition of a Foreign Proceeding page 1

Debtor _______________________________________________________ Case number (if known)_____________________________________ Name

8. Others entitled to notice Attach a list containing the names and addresses of: (i) all persons or bodies authorized to administer foreign proceedings of the debtor, (ii) all parties to litigation pending in the United States in which the debtor is a party at the time of filing of this petition, and (iii) all entities against whom provisional relief is being sought under § 1519 of the Bankruptcy Code.

9. Addresses Country where the debtor has the center of its Debtor’s registered office: main interests: ______________________________________________ ______________________________________________ Number Street _______________________________________________ P.O. Box _______________________________________________ City State/Province/Region ZIP/Postal Code _______________________________________________ Country Individual debtor’s habitual residence: Address of foreign representative(s): _______________________________________________ _______________________________________________ Number Street Number Street _______________________________________________ _______________________________________________ P.O. Box P.O. Box _______________________________________________ _______________________________________________ City State/Province/Region ZIP/Postal Code City State/Province/Region ZIP/Postal Code

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Country Country

10. Debtor’s website (URL) ____________________________________________________________________________________________________

11. Type of debtor Check one: Non-individual (check one): Corporation. Attach a corporate ownership statement containing the information described in Fed. R. Bankr. P. 7007.1. Partnership Other. Specify: ________________________________________________ Individual

Official Form 401 Chapter 15 Petition for Recognition of a Foreign Proceeding page 2

Debtor _______________________________________________________ Case number (if known)_____________________________________ Name

12. Why is venue proper in this Check one: district? Debtor’s principal place of business or principal assets in the United States are in this district. Debtor does not have a place of business or assets in the United States, but the following action or proceeding in a federal or state court is pending against the debtor in this district: ___________________________________________________________________________. If neither box is checked, venue is consistent with the interests of justice and the convenience of the parties, having regard to the relief sought by the foreign representative, because: ___________________________________________________________________________.

13. Signature of foreign I request relief in accordance with chapter 15 of title 11, United States Code. representative(s)

    I am the foreign representative of a debtor in a foreign proceeding, the debtor is eligible for the
    relief sought in this petition, and I am authorized to file this petition.

    I have examined the information in this petition 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,
    ________________________________________________ _______________________________________________
    Signature of foreign representative Printed name

    Executed on __________________
    MM / DD / YYYY
    ________________________________________________ _______________________________________________
    Signature of foreign representative Printed name

    Executed on __________________
    MM / DD / YYYY

14. Signature of attorney _________________________________________________ Date _________________ Signature of Attorney for foreign representative MM / DD / YYYY _________________________________________________________________________________________________ Printed name

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Firm name

_________________________________________________________________________________________________
Number Street

____________________________________________________ __________________________________________
City State ZIP Code

____________________________________ __________________________________________
Contact phone Email address

______________________________________________________ ____________
Bar number State

Official Form 401 Chapter 15 Petition for Recognition of a Foreign Proceeding page 3