FORM B10 (Official Form 10) (9/97)

+---------+----+--------+--------+---+--------------+--------------------+
| ## UN   |    |        |        |   |              | # PROOF OF CLAIM   |
| ITED ST |    |        |        |   |              |                    |
| ATES BA |    |        |        |   |              |                    |
| NKRUPTC |    |        |        |   |              |                    |
| Y COURT |    |        |        |   |              |                    |
|         |    |        |        |   |              |                    |
| ##      |    |        |        |   |              |                    |
|  MIDDLE |    |        |        |   |              |                    |
|  DISTRI |    |        |        |   |              |                    |
| CT OF G |    |        |        |   |              |                    |
| EORGIA  |    |        |        |   |              |                    |
|         |    |        |        |   |              |                    |
| ##      |    |        |        |   |              |                    |
+---------+----+--------+--------+---+--------------+--------------------+
| In re   |    |        | C      |   |              |                    |
|         |    |        | hapter |   |              |                    |
| Wel     |    |        | 11     |   |              |                    |
| lington |    |        | Case   |   |              |                    |
| Leisure |    |        | No.    |   |              |                    |
| Pr      |    |        |        |   |              |                    |
| oducts, |    |        | 03     |   |              |                    |
| Inc.,   |    |        | -30202 |   |              |                    |
| [e      |    |        | (rfh)  |   |              |                    |
| t]{.und |    |        | Proced |   |              |                    |
| erline} |    |        | urally |   |              |                    |
| [al     |    |        | Consol |   |              |                    |
| ]{.unde |    |        | idated |   |              |                    |
| rline}. |    |        |        |   |              |                    |
+---------+----+--------+--------+---+--------------+--------------------+
| Name of |    |        |        | C |              |                    |
| Debtor  |    |        |        | a |              |                    |
| Against |    |        |        | s |              |                    |
| Which   |    |        |        | e |              |                    |
| You     |    |        |        | N |              |                    |
| Assert  |    |        |        | u |              |                    |
| Your    |    |        |        | m |              |                    |
| Claim:  |    |        |        | b |              |                    |
|         |    |        |        | e |              |                    |
| ######  |    |        |        | r |              |                    |
|         |    |        |        | o |              |                    |
|         |    |        |        | f |              |                    |
|         |    |        |        | D |              |                    |
|         |    |        |        | e |              |                    |
|         |    |        |        | b |              |                    |
|         |    |        |        | t |              |                    |
|         |    |        |        | o |              |                    |
|         |    |        |        | r |              |                    |
|         |    |        |        | : |              |                    |
+---------+----+--------+--------+---+--------------+--------------------+
| NOTE:   |    |        |        |   |              |                    |
| This    |    |        |        |   |              |                    |
| form    |    |        |        |   |              |                    |
| should  |    |        |        |   |              |                    |
| not be  |    |        |        |   |              |                    |
| used to |    |        |        |   |              |                    |
| make a  |    |        |        |   |              |                    |
| claim   |    |        |        |   |              |                    |
| for an  |    |        |        |   |              |                    |
| adminis |    |        |        |   |              |                    |
| trative |    |        |        |   |              |                    |
| expense |    |        |        |   |              |                    |
| arising |    |        |        |   |              |                    |
| after   |    |        |        |   |              |                    |
| the     |    |        |        |   |              |                    |
| comme   |    |        |        |   |              |                    |
| ncement |    |        |        |   |              |                    |
| of the  |    |        |        |   |              |                    |
| case. A |    |        |        |   |              |                    |
| \"re    |    |        |        |   |              |                    |
| quest\" |    |        |        |   |              |                    |
| for     |    |        |        |   |              |                    |
| payment |    |        |        |   |              |                    |
| of an   |    |        |        |   |              |                    |
| adminis |    |        |        |   |              |                    |
| trative |    |        |        |   |              |                    |
| expense |    |        |        |   |              |                    |
| may be  |    |        |        |   |              |                    |
| filed   |    |        |        |   |              |                    |
| p       |    |        |        |   |              |                    |
| ursuant |    |        |        |   |              |                    |
| to 11   |    |        |        |   |              |                    |
| U.S.C.  |    |        |        |   |              |                    |
| § 503.  |    |        |        |   |              |                    |
+---------+----+--------+--------+---+--------------+--------------------+
| Name of |    |        |        |   | > Check box  |                    |
| C       |    |        |        |   | > if you are |                    |
| reditor |    |        |        |   | > aware      |                    |
| (The    |    |        |        |   | >            |                    |
| person  |    |        |        |   | > that       |                    |
| or      |    |        |        |   | > anyone     |                    |
| entity  |    |        |        |   | > else has   |                    |
| to whom |    |        |        |   | > filed a    |                    |
| the     |    |        |        |   | > proof      |                    |
| debtor  |    |        |        |   |              |                    |
| owes    |    |        |        |   | pr pr of     |                    |
| money   |    |        |        |   | claim        |                    |
| or      |    |        |        |   | relating to  |                    |
| pr      |    |        |        |   | your claim.  |                    |
| operty) |    |        |        |   | Attach copy  |                    |
|         |    |        |        |   | of statement |                    |
| Name    |    |        |        |   | giving       |                    |
| and     |    |        |        |   | particulars. |                    |
| address |    |        |        |   |              |                    |
| where   |    |        |        |   | > Check box  |                    |
| notices |    |        |        |   | > if you     |                    |
| should  |    |        |        |   | > have never |                    |
| be      |    |        |        |   | > received   |                    |
| sent:   |    |        |        |   | > any        |                    |
|         |    |        |        |   | > notices    |                    |
|         |    |        |        |   | > from the   |                    |
|         |    |        |        |   | > bankruptcy |                    |
|         |    |        |        |   | > court in   |                    |
|         |    |        |        |   | > this case. |                    |
|         |    |        |        |   | >            |                    |
|         |    |        |        |   | > Check box  |                    |
|         |    |        |        |   | > if the     |                    |
|         |    |        |        |   | > address    |                    |
|         |    |        |        |   | > differs    |                    |
|         |    |        |        |   | > from the   |                    |
|         |    |        |        |   | > address on |                    |
|         |    |        |        |   | > the        |                    |
|         |    |        |        |   | > envelope   |                    |
|         |    |        |        |   | > sent to    |                    |
|         |    |        |        |   | > you by the |                    |
|         |    |        |        |   | > court.     |                    |
+---------+----+--------+--------+---+--------------+--------------------+
| Account |    |        |        |   | Check here   |                    |
| Or      |    |        |        |   | replaces     |                    |
| Other   |    |        |        |   |              |                    |
| Number  |    |        |        |   | If this      |                    |
| By      |    |        |        |   | claim amends |                    |
| Which   |    |        |        |   | a previously |                    |
| C       |    |        |        |   | filed claim, |                    |
| reditor |    |        |        |   | dated        |                    |
| Ide     |    |        |        |   |              |                    |
| ntifies |    |        |        |   |              |                    |
| Debtor: |    |        |        |   |              |                    |
+---------+----+--------+--------+---+--------------+--------------------+
| 1\.     |    | -      |        |   | -   Retiree  |                    |
| [Basis  |    |    Sev |        |   |     Benefits |                    |
| For     |    | erance |        |   |     as       |                    |
| Claim]  |    |        |        |   |     defined  |                    |
| {.small |    |    Agr |        |   |     in 11    |                    |
| caps}:\ |    | eement |        |   |     U.S.C. § |                    |
| Goods   |    |        |        |   |     1114(a)  |                    |
| sold\   |    | -      |        |   |              |                    |
| S       |    | Refund |        |   | -   Wages,   |                    |
| ervices |    |        |        |   |              |                    |
| pe      |    | Real   |        |   |    salaries, |                    |
| rformed |    | Pr     |        |   |     and      |                    |
|         |    | operty |        |   |              |                    |
| > Money |    | Lease\ |        |   | compensation |                    |
| >       |    | Pe     |        |   |     (Fill    |                    |
|  loaned |    | rsonal |        |   |     out      |                    |
|         |    | Pr     |        |   |     below)   |                    |
| -   P   |    | operty |        |   |              |                    |
| ersonal |    | Lease  |        |   | > Your SS#   |                    |
|     i   |    |        |        |   | > \_\_       |                    |
| njury/w |    | Other  |        |   | \_\_\_\_\_\_ |                    |
| rongful |    |        |        |   | \_\_\_\_\_\_ |                    |
|         |    |        |        |   | \_\_\_\_\_\_ |                    |
|   death |    |        |        |   | \_\_\_\_\_\_ |                    |
|         |    |        |        |   | \_\_\_\_\_\_ |                    |
| -       |    |        |        |   | >            |                    |
|  Taxes\ |    |        |        |   | > Unpaid     |                    |
|         |    |        |        |   | >            |                    |
|   Other |    |        |        |   | Compensation |                    |
|     :   |    |        |        |   | > for        |                    |
|         |    |        |        |   | > services   |                    |
|         |    |        |        |   | > performed  |                    |
|         |    |        |        |   | >            |                    |
|         |    |        |        |   | > From:      |                    |
|         |    |        |        |   | >            |                    |
|         |    |        |        |   | \_\_\_\_\_\_ |                    |
|         |    |        |        |   | \_\_\_\_\_\_ |                    |
|         |    |        |        |   | \_\_\_\_\_\_ |                    |
|         |    |        |        |   | > to:        |                    |
|         |    |        |        |   | > \_         |                    |
|         |    |        |        |   | \_\_\_\_\_\_ |                    |
|         |    |        |        |   | \_\_\_\_\_\_ |                    |
|         |    |        |        |   | \_\_\_\_\_\_ |                    |
|         |    |        |        |   | >            |                    |
|         |    |        |        |   | > (Date)     |                    |
|         |    |        |        |   | > (Date)     |                    |
+---------+----+--------+--------+---+--------------+--------------------+
| 2\.     |    |        |        |   | 3\. If court |                    |
| Date    |    |        |        |   | judgment,    |                    |
| debt    |    |        |        |   | date         |                    |
| was     |    |        |        |   | obtained:    |                    |
| in      |    |        |        |   |              |                    |
| curred: |    |        |        |   |              |                    |
+---------+----+--------+--------+---+--------------+--------------------+
| 4\.     |    |        |        |   |              |                    |
| Total   |    |        |        |   |              |                    |
| Amount  |    |        |        |   |              |                    |
| Of      |    |        |        |   |              |                    |
| Claim   |    |        |        |   |              |                    |
| At Time |    |        |        |   |              |                    |
| Case    |    |        |        |   |              |                    |
| Filed:  |    |        |        |   |              |                    |
| \$\_\   |    |        |        |   |              |                    |
| _\_\_\_ |    |        |        |   |              |                    |
| \_\_\_\ |    |        |        |   |              |                    |
| _\_\_\_ |    |        |        |   |              |                    |
| \_\_\_\ |    |        |        |   |              |                    |
| _\_\_\_ |    |        |        |   |              |                    |
| \_\_\_\ |    |        |        |   |              |                    |
| _\_\_\_ |    |        |        |   |              |                    |
|         |    |        |        |   |              |                    |
| If all  |    |        |        |   |              |                    |
| or part |    |        |        |   |              |                    |
| of your |    |        |        |   |              |                    |
| claim   |    |        |        |   |              |                    |
| is      |    |        |        |   |              |                    |
| secured |    |        |        |   |              |                    |
| or      |    |        |        |   |              |                    |
| e       |    |        |        |   |              |                    |
| ntitled |    |        |        |   |              |                    |
| to      |    |        |        |   |              |                    |
| pr      |    |        |        |   |              |                    |
| iority, |    |        |        |   |              |                    |
| also    |    |        |        |   |              |                    |
| c       |    |        |        |   |              |                    |
| omplete |    |        |        |   |              |                    |
| Item 5  |    |        |        |   |              |                    |
| or 6    |    |        |        |   |              |                    |
| below.  |    |        |        |   |              |                    |
|         |    |        |        |   |              |                    |
| Check   |    |        |        |   |              |                    |
| this    |    |        |        |   |              |                    |
| box if  |    |        |        |   |              |                    |
| claim   |    |        |        |   |              |                    |
| i       |    |        |        |   |              |                    |
| ncludes |    |        |        |   |              |                    |
| i       |    |        |        |   |              |                    |
| nterest |    |        |        |   |              |                    |
| or      |    |        |        |   |              |                    |
| other   |    |        |        |   |              |                    |
| charges |    |        |        |   |              |                    |
| in      |    |        |        |   |              |                    |
| a       |    |        |        |   |              |                    |
| ddition |    |        |        |   |              |                    |
| to the  |    |        |        |   |              |                    |
| pr      |    |        |        |   |              |                    |
| incipal |    |        |        |   |              |                    |
| amount  |    |        |        |   |              |                    |
| of the  |    |        |        |   |              |                    |
| claim.  |    |        |        |   |              |                    |
| Attach  |    |        |        |   |              |                    |
| i       |    |        |        |   |              |                    |
| temized |    |        |        |   |              |                    |
| st      |    |        |        |   |              |                    |
| atement |    |        |        |   |              |                    |
| of all  |    |        |        |   |              |                    |
| i       |    |        |        |   |              |                    |
| nterest |    |        |        |   |              |                    |
| or      |    |        |        |   |              |                    |
| add     |    |        |        |   |              |                    |
| itional |    |        |        |   |              |                    |
| c       |    |        |        |   |              |                    |
| harges. |    |        |        |   |              |                    |
+---------+----+--------+--------+---+--------------+--------------------+
| 5\.     |    |        |        |   | 6\.          |                    |
| Secured |    |        |        |   | Unsecured    |                    |
| Claim.  |    |        |        |   | Priority     |                    |
|         |    |        |        |   | Claim.       |                    |
| Check   |    |        |        |   |              |                    |
| this    |    |        |        |   | Check this   |                    |
| box if  |    |        |        |   | box if you   |                    |
| your    |    |        |        |   | have an      |                    |
| claim   |    |        |        |   | unsecured    |                    |
| is      |    |        |        |   | priority     |                    |
| secured |    |        |        |   | claim        |                    |
| by      |    |        |        |   |              |                    |
| col     |    |        |        |   | Amount       |                    |
| lateral |    |        |        |   | entitled to  |                    |
| (in     |    |        |        |   | priority     |                    |
| cluding |    |        |        |   | \$\_\_       |                    |
| a right |    |        |        |   | \_\_\_\_\_\_ |                    |
| of      |    |        |        |   | \_\_\_\_\_\_ |                    |
| s       |    |        |        |   | \_\_\_\_\_\_ |                    |
| etoff). |    |        |        |   | \_\_\_\_\_\_ |                    |
|         |    |        |        |   | \_\_\_\_\_\_ |                    |
| Brief   |    |        |        |   |              |                    |
| desc    |    |        |        |   | Specify the  |                    |
| ription |    |        |        |   | priority of  |                    |
| of      |    |        |        |   | the claim    |                    |
| Coll    |    |        |        |   |              |                    |
| ateral: |    |        |        |   | Wages,       |                    |
|         |    |        |        |   | salaries, or |                    |
| Real    |    |        |        |   | commissions  |                    |
| Estate  |    |        |        |   | (up to       |                    |
| Motor   |    |        |        |   | \$4,650),    |                    |
| Vehicle |    |        |        |   | earned       |                    |
| Other   |    |        |        |   | within 90    |                    |
| \_\     |    |        |        |   | days before  |                    |
| _\_\_\_ |    |        |        |   | filing       |                    |
| \_\_\_\ |    |        |        |   |              |                    |
| _\_\_\_ |    |        |        |   | of the       |                    |
| \_\_\_\ |    |        |        |   | bankruptcy   |                    |
| _\_\_\_ |    |        |        |   | petition or  |                    |
| \_\_\_\ |    |        |        |   | cessation of |                    |
| _\_\_\_ |    |        |        |   | the          |                    |
|         |    |        |        |   | debtor\'s    |                    |
| Value   |    |        |        |   | business,    |                    |
| of      |    |        |        |   | whichever is |                    |
| Coll    |    |        |        |   | earlier      |                    |
| ateral: |    |        |        |   |              |                    |
|         |    |        |        |   | ‑- 11 U.S.C. |                    |
| Amount  |    |        |        |   | § 507(a)(3)  |                    |
| of      |    |        |        |   |              |                    |
| ar      |    |        |        |   | C            |                    |
| rearage |    |        |        |   | ontributions |                    |
| and     |    |        |        |   | to an        |                    |
| other   |    |        |        |   | employee     |                    |
| charges |    |        |        |   | benefit plan |                    |
| [at     |    |        |        |   | ‑- 11 U.S.C. |                    |
| time    |    |        |        |   | § 507(a)(4)  |                    |
| case    |    |        |        |   |              |                    |
| file    |    |        |        |   | Up to        |                    |
| d]{.und |    |        |        |   | \$1,950 of   |                    |
| erline} |    |        |        |   | deposits     |                    |
| i       |    |        |        |   | toward       |                    |
| ncluded |    |        |        |   | purchase,    |                    |
| in      |    |        |        |   | lease, or    |                    |
| secured |    |        |        |   | rental of    |                    |
| claim,  |    |        |        |   | property or  |                    |
| if any  |    |        |        |   |              |                    |
|         |    |        |        |   | services for |                    |
| \$ .    |    |        |        |   | personal,    |                    |
|         |    |        |        |   | family, or   |                    |
|         |    |        |        |   | household    |                    |
|         |    |        |        |   | use ‑- 11    |                    |
|         |    |        |        |   | U.S.C.       |                    |
|         |    |        |        |   | § 507(a)(6)  |                    |
|         |    |        |        |   |              |                    |
|         |    |        |        |   | Alimony,     |                    |
|         |    |        |        |   | maintenance, |                    |
|         |    |        |        |   | or support   |                    |
|         |    |        |        |   | owed to a    |                    |
|         |    |        |        |   | spouse,      |                    |
|         |    |        |        |   | former       |                    |
|         |    |        |        |   | spouse, or   |                    |
|         |    |        |        |   |              |                    |
|         |    |        |        |   | child -- 11  |                    |
|         |    |        |        |   | U.S.C.  §    |                    |
|         |    |        |        |   | 507(a)(7)    |                    |
|         |    |        |        |   |              |                    |
|         |    |        |        |   | Taxes or     |                    |
|         |    |        |        |   | penalties of |                    |
|         |    |        |        |   | governmental |                    |
|         |    |        |        |   | units ‑- 11  |                    |
|         |    |        |        |   | U.S.C.       |                    |
|         |    |        |        |   | § 507(a)(8)  |                    |
|         |    |        |        |   |              |                    |
|         |    |        |        |   | Other --     |                    |
|         |    |        |        |   | specify      |                    |
|         |    |        |        |   | applicable   |                    |
|         |    |        |        |   | paragraph of |                    |
|         |    |        |        |   | 11 U.S.C.    |                    |
|         |    |        |        |   | § 507        |                    |
|         |    |        |        |   | (a)(\_\_\_), |                    |
+---------+----+--------+--------+---+--------------+--------------------+
| 7\.     |    |        |        |   |              | This Space Is For  |
| C       |    |        |        |   |              | Court Use Only     |
| redits: |    |        |        |   |              |                    |
| The     |    |        |        |   |              |                    |
| amount  |    |        |        |   |              |                    |
| of all  |    |        |        |   |              |                    |
| p       |    |        |        |   |              |                    |
| ayments |    |        |        |   |              |                    |
| on this |    |        |        |   |              |                    |
| claim   |    |        |        |   |              |                    |
| has     |    |        |        |   |              |                    |
| been    |    |        |        |   |              |                    |
| c       |    |        |        |   |              |                    |
| redited |    |        |        |   |              |                    |
| and     |    |        |        |   |              |                    |
| d       |    |        |        |   |              |                    |
| educted |    |        |        |   |              |                    |
| for the |    |        |        |   |              |                    |
| purpose |    |        |        |   |              |                    |
| of      |    |        |        |   |              |                    |
| making  |    |        |        |   |              |                    |
|         |    |        |        |   |              |                    |
| this    |    |        |        |   |              |                    |
| proof   |    |        |        |   |              |                    |
| of      |    |        |        |   |              |                    |
| claim.  |    |        |        |   |              |                    |
|         |    |        |        |   |              |                    |
| 8\.     |    |        |        |   |              |                    |
| Sup     |    |        |        |   |              |                    |
| porting |    |        |        |   |              |                    |
| Doc     |    |        |        |   |              |                    |
| uments. |    |        |        |   |              |                    |
| *Attach |    |        |        |   |              |                    |
| copies  |    |        |        |   |              |                    |
| of      |    |        |        |   |              |                    |
| sup     |    |        |        |   |              |                    |
| porting |    |        |        |   |              |                    |
| docu    |    |        |        |   |              |                    |
| ments*, |    |        |        |   |              |                    |
| such as |    |        |        |   |              |                    |
| pro     |    |        |        |   |              |                    |
| missory |    |        |        |   |              |                    |
| notes,  |    |        |        |   |              |                    |
| p       |    |        |        |   |              |                    |
| urchase |    |        |        |   |              |                    |
| orders, |    |        |        |   |              |                    |
| in      |    |        |        |   |              |                    |
| voices, |    |        |        |   |              |                    |
|         |    |        |        |   |              |                    |
| i       |    |        |        |   |              |                    |
| temized |    |        |        |   |              |                    |
| sta     |    |        |        |   |              |                    |
| tements |    |        |        |   |              |                    |
| of      |    |        |        |   |              |                    |
| running |    |        |        |   |              |                    |
| ac      |    |        |        |   |              |                    |
| counts, |    |        |        |   |              |                    |
| con     |    |        |        |   |              |                    |
| tracts, |    |        |        |   |              |                    |
| court   |    |        |        |   |              |                    |
| jud     |    |        |        |   |              |                    |
| gments, |    |        |        |   |              |                    |
| mor     |    |        |        |   |              |                    |
| tgages, |    |        |        |   |              |                    |
| s       |    |        |        |   |              |                    |
| ecurity |    |        |        |   |              |                    |
| agre    |    |        |        |   |              |                    |
| ements, |    |        |        |   |              |                    |
| and     |    |        |        |   |              |                    |
| e       |    |        |        |   |              |                    |
| vidence |    |        |        |   |              |                    |
| of      |    |        |        |   |              |                    |
|         |    |        |        |   |              |                    |
| per     |    |        |        |   |              |                    |
| fection |    |        |        |   |              |                    |
| of      |    |        |        |   |              |                    |
| lien.   |    |        |        |   |              |                    |
| DO NOT  |    |        |        |   |              |                    |
| SEND    |    |        |        |   |              |                    |
| O       |    |        |        |   |              |                    |
| RIGINAL |    |        |        |   |              |                    |
| DOC     |    |        |        |   |              |                    |
| UMENTS. |    |        |        |   |              |                    |
| If the  |    |        |        |   |              |                    |
| do      |    |        |        |   |              |                    |
| cuments |    |        |        |   |              |                    |
| are not |    |        |        |   |              |                    |
| ava     |    |        |        |   |              |                    |
| ilable, |    |        |        |   |              |                    |
| e       |    |        |        |   |              |                    |
| xplain. |    |        |        |   |              |                    |
| If the  |    |        |        |   |              |                    |
|         |    |        |        |   |              |                    |
| do      |    |        |        |   |              |                    |
| cuments |    |        |        |   |              |                    |
| are     |    |        |        |   |              |                    |
| volu    |    |        |        |   |              |                    |
| minous, |    |        |        |   |              |                    |
| attach  |    |        |        |   |              |                    |
| a       |    |        |        |   |              |                    |
| s       |    |        |        |   |              |                    |
| ummary. |    |        |        |   |              |                    |
|         |    |        |        |   |              |                    |
| 9\.     |    |        |        |   |              |                    |
| Date-   |    |        |        |   |              |                    |
| Stamped |    |        |        |   |              |                    |
| Copy:   |    |        |        |   |              |                    |
| To      |    |        |        |   |              |                    |
| receive |    |        |        |   |              |                    |
| an      |    |        |        |   |              |                    |
| acknowl |    |        |        |   |              |                    |
| edgment |    |        |        |   |              |                    |
| of the  |    |        |        |   |              |                    |
| filing  |    |        |        |   |              |                    |
| of your |    |        |        |   |              |                    |
| claim,  |    |        |        |   |              |                    |
| enclose |    |        |        |   |              |                    |
| a       |    |        |        |   |              |                    |
| s       |    |        |        |   |              |                    |
| tamped, |    |        |        |   |              |                    |
| self-ad |    |        |        |   |              |                    |
| dressed |    |        |        |   |              |                    |
|         |    |        |        |   |              |                    |
| e       |    |        |        |   |              |                    |
| nvelope |    |        |        |   |              |                    |
| and     |    |        |        |   |              |                    |
| copy of |    |        |        |   |              |                    |
| this    |    |        |        |   |              |                    |
| proof   |    |        |        |   |              |                    |
| of      |    |        |        |   |              |                    |
| claim.  |    |        |        |   |              |                    |
+---------+----+--------+--------+---+--------------+--------------------+
| Date    | Si |        |        |   |              |                    |
|         | gn |        |        |   |              |                    |
|         | a  |        |        |   |              |                    |
|         | nd |        |        |   |              |                    |
|         | p  |        |        |   |              |                    |
|         | ri |        |        |   |              |                    |
|         | nt |        |        |   |              |                    |
|         | t  |        |        |   |              |                    |
|         | he |        |        |   |              |                    |
|         | na |        |        |   |              |                    |
|         | me |        |        |   |              |                    |
|         | a  |        |        |   |              |                    |
|         | nd |        |        |   |              |                    |
|         | ti |        |        |   |              |                    |
|         | tl |        |        |   |              |                    |
|         | e, |        |        |   |              |                    |
|         | if |        |        |   |              |                    |
|         | an |        |        |   |              |                    |
|         | y, |        |        |   |              |                    |
|         | of |        |        |   |              |                    |
|         | t  |        |        |   |              |                    |
|         | he |        |        |   |              |                    |
|         | cr |        |        |   |              |                    |
|         | ed |        |        |   |              |                    |
|         | it |        |        |   |              |                    |
|         | or |        |        |   |              |                    |
|         | or |        |        |   |              |                    |
|         | o  |        |        |   |              |                    |
|         | th |        |        |   |              |                    |
|         | er |        |        |   |              |                    |
|         | pe |        |        |   |              |                    |
|         | rs |        |        |   |              |                    |
|         | on |        |        |   |              |                    |
|         | au |        |        |   |              |                    |
|         | th |        |        |   |              |                    |
|         | or |        |        |   |              |                    |
|         | iz |        |        |   |              |                    |
|         | ed |        |        |   |              |                    |
|         | to |        |        |   |              |                    |
|         | fi |        |        |   |              |                    |
|         | le |        |        |   |              |                    |
|         | th |        |        |   |              |                    |
|         | is |        |        |   |              |                    |
|         | c  |        |        |   |              |                    |
|         | la |        |        |   |              |                    |
|         | im |        |        |   |              |                    |
|         | (  |        |        |   |              |                    |
|         | at |        |        |   |              |                    |
|         | ta |        |        |   |              |                    |
|         | ch |        |        |   |              |                    |
|         | co |        |        |   |              |                    |
|         | py |        |        |   |              |                    |
|         | of |        |        |   |              |                    |
|         | p  |        |        |   |              |                    |
|         | ow |        |        |   |              |                    |
|         | er |        |        |   |              |                    |
|         | of |        |        |   |              |                    |
|         | a  |        |        |   |              |                    |
|         | tt |        |        |   |              |                    |
|         | or |        |        |   |              |                    |
|         | ne |        |        |   |              |                    |
|         | y, |        |        |   |              |                    |
|         | if |        |        |   |              |                    |
|         | a  |        |        |   |              |                    |
|         | ny |        |        |   |              |                    |
|         | ): |        |        |   |              |                    |
+---------+----+--------+--------+---+--------------+--------------------+
| *       |    |        |        |   |              |                    |
| Penalty |    |        |        |   |              |                    |
| for     |    |        |        |   |              |                    |
| pre     |    |        |        |   |              |                    |
| senting |    |        |        |   |              |                    |
| fra     |    |        |        |   |              |                    |
| udulent |    |        |        |   |              |                    |
| claim*: |    |        |        |   |              |                    |
| Fine of |    |        |        |   |              |                    |
| up to   |    |        |        |   |              |                    |
| \$      |    |        |        |   |              |                    |
| 500,000 |    |        |        |   |              |                    |
| or      |    |        |        |   |              |                    |
| impri   |    |        |        |   |              |                    |
| sonment |    |        |        |   |              |                    |
| for up  |    |        |        |   |              |                    |
| to five |    |        |        |   |              |                    |
| years,  |    |        |        |   |              |                    |
| or      |    |        |        |   |              |                    |
| both.   |    |        |        |   |              |                    |
| 18      |    |        |        |   |              |                    |
| U.S.C.  |    |        |        |   |              |                    |
| §§ 152  |    |        |        |   |              |                    |
| and     |    |        |        |   |              |                    |
| 3571.   |    |        |        |   |              |                    |
+---------+----+--------+--------+---+--------------+--------------------+

INSTRUCTIONS FOR FILING PROOF OF CLAIM FORM

*The instructions and definitions below are general explanations of the
law. In particular types of cases or circumstances, such as bankruptcy
cases that are not filed voluntarily by a debtor, there may be
exceptions to the general rules*.

--- DEFINITIONS ---

+------------------------+------------------------+-------------------+
| ***DEBTOR***           | ***SECURED CLAIM***    | ########          |
|                        |                        | # UNSECURED CLAIM |
| The person,            | ***A claim is a        |                   |
| corporation, or other  | secured*** claim to    | If a claim is not |
| entity that has filed  | the extent that the    | a secured claim   |
| a bankruptcy case is   | creditor has a lien on | it is an          |
| called the debtor.     | property of the debtor | unsecured claim.  |
|                        | (collateral) that      | A claim may be    |
| ***CREDITOR***         | gives the creditor the | partly secured    |
|                        | right to be paid from  | and partly        |
| A creditor is any      | that property before   | unsecured if the  |
| person, corporation,   | creditors who do not   | property on which |
| or other entity to     | have liens on the      | a creditor has a  |
| whom the debtor owed a | property.              | lien is not worth |
| debt on the date that  |                        | enough to pay the |
| the bankruptcy case    | Examples of liens are  | creditor in full. |
| was filed.             | a mortgage on real     |                   |
|                        | estate and a security  | ***UNSECURED      |
| ***PROOF OF CLAIM***   | interest in a car,     | PRIORITY CLAIM*** |
|                        | truck, boat,           |                   |
| A form telling the     | television set, or     | Certain types of  |
| bankruptcy court how   | other item of          | unsecured claims  |
| much the debtor owed a | property. A lien may   | are given         |
| creditor at the time   | have been obtained     | priority, so they |
| the bankruptcy case    | through a court        | are to be paid in |
| was filed (the amount  | proceeding before the  | bankruptcy cases  |
| of the creditor's      | bankruptcy case began; | before most other |
| claim). This form must | in some states a court | unsecured claims  |
| be filed with the      | judgment is a lien. In | (if there is      |
| clerk of the           | addition to the extent | sufficient money  |
| bankruptcy court where | a creditor also owes   | or property       |
| the bankruptcy case    | money to the debtor    | available to pay  |
| was filed.             | (has a right of        | these claims).    |
|                        | setoff), the creditors | The most common   |
|                        | claim may be a secured | types of priority |
|                        | claim. (See also       | claims are listed |
|                        | *Unsecured Claim.*)    | on the proof of   |
|                        |                        | claim form.       |
|                        |                        | Unsecured claims  |
|                        |                        | that are not      |
|                        |                        | specifically      |
|                        |                        | given priority    |
|                        |                        | status by the     |
|                        |                        | bankruptcy laws   |
|                        |                        | are classified as |
|                        |                        | *Unsecured        |
|                        |                        | Nonpriority       |
|                        |                        | Claims.*          |
+------------------------+------------------------+-------------------+

**Items to be completed in Proof of Claim form (if not already filled
in)**

+-------------------------------------+--------------------------------+
| **Court**, **Name of Debtor, and    | **4. Total Amount of Claim at  |
| Case Number:**                      | Time Case Filed**              |
|                                     |                                |
| Fill in the name of the federal     | Fill in the amount of the      |
| judicial district where the         | entire claim. If interest or   |
| bankruptcy case was filed (for      | other changes in addition to   |
| example, Western District of        | the principal amount of the    |
| Washington), the name of the debtor | claim are included check the   |
| in the bankruptcy case, and the     | appropriate place on the form  |
| bankruptcy case number. If you      | and attach an itemization of   |
| received a notice of the case from  | the interest and charges.      |
| the court, all of this information  |                                |
| is near the top of the notice.      | **5. Secured Claim:**          |
|                                     |                                |
| **Information about Creditor:**     | Check the appropriate place if |
|                                     | the claim is a secured claim.  |
| Complete the section giving the     | You must state the type and    |
| name, address, and telephone number | value of property that is      |
| of the creditor to whom the debtor  | collateral for the claim,      |
| owes money or property, and the     | attach copies of the           |
| debtor's account number, if any. If | documentation of your lien,    |
| anyone else has already filed a     | and state the amount past due  |
| proof of claim relating to this     | on the claim as of the date    |
| debt, if you never received notices | the bankruptcy case was filed. |
| from the bankruptcy court ab out    | A claim may be partly secured  |
| this case, if your address differs  | and partly unsecured (See      |
| from that to which the court sent   | DEFINITIONS, above).           |
| notice, or if this proof of claim   |                                |
| replaces or changes a proof of      | **6. Unsecured Priority        |
| claim that was already filed, check | Claim:**                       |
| the appropriate box on the form.    |                                |
|                                     | Check the appropriate place if |
| **1. Basis for Claim:**             | you have an unsecured priority |
|                                     | claim, and state the amount    |
| Check the type of debt for which    | entitled to priority. (See     |
| the proof of claim is being filed.  | DEFINITIONS, above). A claim   |
| If the type of debt is not listed,  | may be partly priority and     |
| check "Other" and briefly describe  | partly nonpriority if, for     |
| the type of debt. If you were an    | example the claim is for more  |
| employee of the debtor, fill in     | than the amount given priority |
| your social security number and the | by the law. Check the          |
| dates of work for which you were    | appropriate place to specify   |
| not paid.                           | the type of priority claim.    |
|                                     |                                |
| **2. Date Debt Incurred:**          | **7. Credits:**                |
|                                     |                                |
| Fill in the date when the debt      | By signing this proof of       |
| first was owed by the debtor.       | claim, you are stating under   |
|                                     | oath that in calculating the   |
| **3. Court Judgments:**             | amount of your claim you have  |
|                                     | given the debtor credit for    |
| If you have a court judgment for    | all payments received from the |
| this debt, state the date the court | debtor.                        |
| entered the judgment.               |                                |
|                                     | **8. Supporting Documents:**   |
|                                     |                                |
|                                     | You must attach to this proof  |
|                                     | of claim form copies of        |
|                                     | documents that show the debtor |
|                                     | owes the debt claimed or, if   |
|                                     | the documents are too lengthy, |
|                                     | a summary of those documents.  |
|                                     | If documents are not available |
|                                     | you must attach an explanation |
|                                     | of why they are not available. |
+-------------------------------------+--------------------------------+