CACB — Unsecured Claims and Are Not Insiders (204)

Source: https://www.cacb.uscourts.gov/sites/cacb/files/documents/forms/204.pdf

Fill in this information to identify the case:

Debtor name __________________________________________________________________
United States Bankruptcy Court for the: ______________________ District of _________
(State) Check if this is an
Case number (If known): _________________________ amended filing

Official Form 204 Chapter 11 or Chapter 9 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims and Are Not Insiders 12/15

A list of creditors holding the 20 largest unsecured claims must be filed in a Chapter 11 or Chapter 9 case. Include claims which the debtor disputes. Do not include claims by any person or entity who is an insider, as defined in 11 U.S.C. § 101(31). 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.

Name of creditor and complete Name, telephone number, and Nature of the claim Indicate if Amount of unsecured claim mailing address, including zip code email address of creditor (for example, trade claim is If the claim is fully unsecured, fill in only unsecured contact debts, bank loans, contingent, claim amount. If claim is partially secured, fill in professional unliquidated, total claim amount and deduction for value of services, and or disputed collateral or setoff to calculate unsecured claim. government contracts) Total claim, if Deduction for Unsecured partially value of claim secured collateral or setoff 1

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Official Form 204 Chapter 11 or Chapter 9 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 1

Debtor _______________________________________________________ Case number (if known)_____________________________________ Name

Name of creditor and complete Name, telephone number, and Nature of the claim Indicate if Amount of unsecured claim mailing address, including zip code email address of creditor (for example, trade claim is If the claim is fully unsecured, fill in only unsecured contact debts, bank loans, contingent, claim amount. If claim is partially secured, fill in professional unliquidated, total claim amount and deduction for value of services, and or disputed collateral or setoff to calculate unsecured claim. government contracts) Total claim, if Deduction for Unsecured partially value of claim secured collateral or setoff

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Official Form 204 Chapter 11 or Chapter 9 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 2