CASB — Proof of Interest (CSD3002)

Source: https://www.casb.uscourts.gov/sites/casb/files/documents/forms/CSD3002_0.pdf

CSD 3002 [12/01/22] UNITED STATES BANKRUPTY COURT PROOF OF INTEREST SOUTHERN DISTRICT OF CALIFORNIA Name of Debtor(s): Case Number:

1. Name of holder of the Equity Security Interest (The ☐Check box if you are person or entity holding an Equity Security Interest in the aware that anyone else has Debtor. Referred to hereinafter as the “Interest Holder”): filed a proof of interest relating to your interest. Attach copy of statement giving particulars.

Name and address where notices should be sent: ☐Check box if you have never received any noticed from the bankruptcy court or the Debtors case.

☐Check box if this address differs from the address on

Telephone Number: the envelope sent to you by Debtors. NOTE: This form SHOULD NOT be used to make a claim against the Debtor for money owed. A separate Proof of Claim form should be used for that purpose. This form should only be used to assert an Equity Security Interest in the Debtor. An Equity Security Interest is any right arising from any capital stock and any equity security in any of the Debtor. An equity security is defined in the Bankruptcy Code as (a) a share in a corporation whether or not transferable or denominated stock or similar security, (b) interest of a limited partner in a limited partnership, or (c) warrant or right other than a right to convert, to purchase, sell, or subscribe to a share, security, or interest of a kind specified in subparagraph (a) or (b)above. THIS SPACE FOR COURT USE ONLY Account or other number by which Interest Holder identifies Debtor: Check here if this claim: ☐replaces a previously filed Proof of Interest, dated:

☐amends a previously filed Proof of Interest, dated:

2. Name and Address of any person or entity that is the record 3. Date Equity Security Interest was acquired: holder for the Equity Security Interest asserted in the Proof of Interest:

Telephone Number: 4. Total amount of member interest: 5. Certificate number(s):

6. Type of Equity Interest:

Please indicate the type of Equity Interest you hold:

7. Supporting Documents: Attach copies of supporting documents, such as stock certificates, option agreements, warrants, etc. DO NOT SEND ORIGINAL DOCUMENTS. If the documents are not available, explain on additional sheet.
8. Signature: THIS SPACE FOR COURT USE ONLY

I declare under penalty of perjury that the information provided in this proof of interest is true and correct to the best of my knowledge, information and reasonable belief. DATE: SIGN and print the name and title, if any, of the Interest Holder or other person authorized to file this proof of interest (attach copy of power of attorney, if any):

Penalty for presenting fraudulent claim is a fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §§ 152 AND 3571