Proof of Claim Form

Onstine Receivership Public Notice
Proof of Claim
PART 1: IDENTIFYING INFORMATION
Claimant
Name

First NameMiddle InitialLast Name
Jr/Sr/III
Name of Entity
Mailing Address
City
State/Prov.
Zip Code (Postal Code)
Country
Phone Number
Work Number (if applicable)
Email address
example@example.com
Claimant's Attorney, if Any
Law Firm Name
Name

Attorneys First NameMiddle InitialLast Name
Street Address
City
State/Prov.
Zip Code (Postal Code)
Country
Phone Number
Format: (000) 000-0000.
Fax No
Email address
example@example.com
PART2: NATURE OF CLAIM
What Type of Claim Do You Have?
What Type of Claim Do You Have?
If other, provide an explanation, not applicable type N/A
How many shares are owned?
List Stock Certificate Numbers
When were your shares acquired and in what number? Specify multiple dates
What is your tax basis for your shares or equity security interest?
Is your claim based on an unpaid obligation or other debt to you?
Please provide a complete description of the nature and date of the claim.
A. Where and when you commenced the lawsuit:
B. The case number of the lawsuit:
C. The result of the lawsuit:
Sign your name below. If you are signing the POC on behalf of another person or an estate, print your title, and provide proof of authority to sign.

Under penalty of perjury, I declare the foregoing statements to be true and correct.
Date

MonthDayYear
Date
Name

First NameLast Name
Signature Print Name
Name of Entity
Relationship to Entity
Scan and upload stock certificates to the website, or attach and mail copies of all stock certificates to one of the addresses provided above
File Upload

Cancelof
Should be Empty:

Onstine Receivership Public Notice

Proof of Claim

PART 1: IDENTIFYING INFORMATION

Claimant

Claimant's Attorney, if Any

PART2: NATURE OF CLAIM

Scan and upload stock certificates to the website, or attach and mail copies of all stock certificates to one of the addresses provided above