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Office of the U.S. Trustee
- Chicago, IL
MEETING OF THE LARGEST UNSECURED
CREDITORS
IN RE: _________________________________
CASE
NO. _______________ __
1. NAME OF CREDITOR (Please
Print)
Name Address (include suite# &
zip code) Telephone, Fax& E-Mail
_______________________________________________________________________________________
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NAME OF CREDITOR'S REPRESENTATIVE
(Please Print)
Name Address (if different) Telephone,
Fax& E-Mail (if different)
_____________________________________________________________________________________________
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AMOUNT OF UNSECURED CLAIM: __________________________________________________
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AMOUNT, IF ANY, OF SECURED CLAIM, INCLUDING
ANY LETTERS OF CREDIT, MECHANIC'S LIENS, OR ANY OTHER LIENS: _________________________________________________________________
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TYPE OF CLAIM: Please complete
the appropriate line:
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Trade: _________________________________________________________________________
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Have you, or do you intend to, file a
claim for reclamation, and if so, please state the amount of such reclamation
claim:___________________________________________
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Is any part of your claim subject to a
consignment agreement, and if so, please state the amount of such consignment:
_______________________________________________
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Have you sold or assigned this receivable
to a factor, and if so, please state the amount sold or assigned as well
as the name of such factor:__________________________________________________________________
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Landlord: _____________________________________________
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Bank or Other Lending/Financial Institution:
________________________________________ ______________________________________________________________________________
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Bondholder/Investor:
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Factor:
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Other (please specify): _______________________________
_
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PLEASE DESCRIBE THE TYPE OF PRODUCT
OR SERVICE YOU SUPPLY TO THE DEBTOR:______________________________________________________________________________
_____________________________________________________________________________________________
7. DO YOU HAVE, OR HAVE YOU HAD
IN THE PAST, ANY AFFILIATION WITH THE DEBTOR (i.e.: ARE YOU AN EQUITY HOLDER,
AFFILIATE OR INSIDER)? ___________________________________________________
_____________________________________________________________________________________________
8. IS THERE ANY OTHER INFORMATION
YOU BELIEVE IS RELEVANT AS TO WHY YOU SHOULD BE APPOINTED TO THE UNSECURED
CREDITORS' COMMITTEE? _____________________________________
____________________________________________________________________________________________
SIGNATURE: ______________________
PRINT NAME: ______________________
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