CACB — Unsecured Claims Against You and Are Not Insiders (104)

Source: https://www.cacb.uscourts.gov/sites/cacb/files/documents/forms/104.pdf

Fill in this information to identify your case:

Debtor 1 __________________________________________________________________ First Name Middle Name Last Name

Debtor 2 ________________________________________________________________ (Spouse, if filing) First Name Middle Name Last Name

United States Bankruptcy Court for the: ______________________ District of __________ (State) Case number ___________________________________________ (If known) Check if this is an amended filing

Official Form 104 For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims Against You and Are Not Insiders 12/15

If you are an individual filing for bankruptcy under Chapter 11, you must fill out this form. If you are filing under Chapter 7, Chapter 12, or Chapter 13, do not fill out this form. Do not include claims by anyone who is an insider. Insiders include your relatives; any general partners; relatives of any general partners; partnerships of which you are a general partner; corporations of which you are an officer, director, person in control, or owner of 20 percent or more of their voting securities; and any managing agent, including one for a business you operate as a sole proprietor. 11 U.S.C. § 101. Also, do not include claims by secured creditors unless the unsecured claim resulting from inadequate collateral value places the creditor among the holders of the 20 largest unsecured claims. Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct information.

Part 1: List the 20 Unsecured Claims in Order from Largest to Smallest. Do Not Include Claims by Insiders.

Unsecured claim

1 What is the nature of the claim? ____________________________ $____________________________ __________________________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. Contingent __________________________________________ Number Street Unliquidated Disputed __________________________________________ None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Contact Yes. Total claim (secured and unsecured): $_____________________ ____________________________________ Value of security: - $_____________________ Contact phone Unsecured claim $_____________________

2 What is the nature of the claim? ____________________________ $____________________________ __________________________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. Contingent __________________________________________ Number Street Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Contact Yes. Total claim (secured and unsecured): $_____________________ Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________

Official Form 104 For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 1

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Unsecured claim

3 __________________________________________ What is the nature of the claim? ____________________________ $____________________________ Creditor’s Name __________________________________________ As of the date you file, the claim is: Check all that apply. Number Street Contingent __________________________________________ Unliquidated Disputed __________________________________________ None of the above apply City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Contact Yes. Total claim (secured and unsecured): $_____________________ ____________________________________ Value of security: - $_____________________ Contact phone Unsecured claim $_____________________

$____________________________ 4 __________________________________________ What is the nature of the claim? ____________________________
Creditor’s Name As of the date you file, the claim is: Check all that apply.
__________________________________________ Contingent
Number Street Unliquidated
__________________________________________ Disputed
None of the above apply
__________________________________________
City State ZIP Code Does the creditor have a lien on your property?
No
__________________________________________ Yes. Total claim (secured and unsecured): $_____________________
Contact Value of security: - $_____________________
____________________________________ Contact phone Unsecured claim $_____________________

5 __________________________________________ What is the nature of the claim? ____________________________ $____________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Number Street Contingent Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________ 6 __________________________________________ What is the nature of the claim? ____________________________ $____________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Number Street Contingent Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________ 7 What is the nature of the claim? ____________________________ $____________________________ __________________________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Contingent Number Street Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________

Official Form 104 For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 2

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Unsecured claim

8 __________________________________________ What is the nature of the claim? ____________________________ $____________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Number Street Contingent Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________ 9 __________________________________________ What is the nature of the claim? ____________________________ $____________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Number Street Contingent Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________

$10 __________________________________________ What is the nature of the claim? ____________________________
Creditor’s Name As of the date you file, the claim is: Check all that apply.
______________ Contingent
Number Street Unliquidated
__________________________________________ Disputed
None of the above apply
__________________________________________
City State ZIP Code Does the creditor have a lien on your property?
No
__________________________________________ Yes. Total claim (secured and unsecured): $_____________________
Contact Value of security: - $_____________________
____________________________________ Contact phone Unsecured claim $_____________________

11 __________________________________________ What is the nature of the claim? ____________________________ $____________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Number Street Contingent Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Contact Yes. Total claim (secured and unsecured): $_____________________ Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________ 12 What is the nature of the claim? ____________________________ $____________________________ __________________________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. Contingent __________________________________________ Number Street Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ Does the creditor have a lien on your property? City State ZIP Code No Yes. Total claim (secured and unsecured): $_____________________ __________________________________________ Contact Value of security: - $_____________________ Unsecured claim $_____________________

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Official Form 104 For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 3

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Unsecured claim

13 __________________________________________ What is the nature of the claim? ____________________________ $____________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Number Street Contingent Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________ 14 __________________________________________ What is the nature of the claim? ____________________________ $____________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Number Street Contingent Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________

$15 __________________________________________ What is the nature of the claim? ____________________________
Creditor’s Name As of the date you file, the claim is: Check all that apply.
______________ Contingent
Number Street Unliquidated
__________________________________________ Disputed
None of the above apply
__________________________________________
City State ZIP Code Does the creditor have a lien on your property?
No
__________________________________________ Yes. Total claim (secured and unsecured): $_____________________
Contact Value of security: - $_____________________
____________________________________ Contact phone Unsecured claim $_____________________

16 __________________________________________ What is the nature of the claim? ____________________________ $____________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Number Street Contingent Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________ 17 What is the nature of the claim? ____________________________ $____________________________ __________________________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Contingent Number Street Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________

Official Form 104 For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 4

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

Unsecured claim

18 What is the nature of the claim? ____________________________ $____________________________ __________________________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Contingent Number Street Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Yes. Total claim (secured and unsecured): $_____________________ Contact Value of security: - $_____________________ ____________________________________ Contact phone Unsecured claim $_____________________

19 What is the nature of the claim? ____________________________ __________________________________________ $____________________________ Creditor’s Name As of the date you file, the claim is: Check all that apply. __________________________________________ Number Street Contingent Unliquidated __________________________________________ Disputed None of the above apply __________________________________________ City State ZIP Code Does the creditor have a lien on your property? No __________________________________________ Contact Yes. Total claim (secured and unsecured): $_____________________ ____________________________________ Value of security: - $_____________________ Contact phone Unsecured claim $_____________________

20 What is the nature of the claim? ____________________________ $____________________________ As of the date you file, the claim is: Check all that apply. Contingent __________________________________________ Creditor’s Name Unliquidated Disputed __________________________________________ Number Street None of the above apply __________________________________________ Does the creditor have a lien on your property? __________________________________________ No City State ZIP Code Yes. Total claim (secured and unsecured): $_____________________ Value of security: - $_____________________ __________________________________________ Contact Unsecured claim $_____________________

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Part 2: Sign Below

Under penalty of perjury, I declare that the information provided in this form is true and correct.

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Signature of Debtor 1 Signature of Debtor 2

Date _________________ Date _________________
MM / DD / YYYY MM / DD / YYYY

Official Form 104 For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 5