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
 

_______________________________________________________________________________________
 

  • NAME OF CREDITOR'S REPRESENTATIVE (Please Print)

  •  
Name Address (if different) Telephone, Fax& E-Mail (if different)
 

_____________________________________________________________________________________________
 

  • AMOUNT OF UNSECURED CLAIM: __________________________________________________

  •  
  • AMOUNT, IF ANY, OF SECURED CLAIM, INCLUDING ANY LETTERS OF CREDIT, MECHANIC'S LIENS, OR ANY OTHER LIENS: _________________________________________________________________

  •  
  • TYPE OF CLAIM: Please complete the appropriate line:
    • Trade: _________________________________________________________________________

    •  
      • Have you, or do you intend to, file a claim for reclamation, and if so, please state the amount of such reclamation claim:___________________________________________
      • Is any part of your claim subject to a consignment agreement, and if so, please state the amount of such consignment: _______________________________________________
      • 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:__________________________________________________________________
    • Landlord: _____________________________________________
    • Bank or Other Lending/Financial Institution: ________________________________________ ______________________________________________________________________________
    • Bondholder/Investor:
    • Factor:
    • Other (please specify): _______________________________ _

 
  • 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: ______________________
 

Page Last Updated on Monday, September 12, 2005

U.S. Trustee Program/Department of Justice

usdoj/ust/r11/mm