EXHIBIT B-1 

Case:17-03283-LTS Doc#:23978-4 Filed:04/11/23 Entered:04/11/23 19:12:50 Desc:

Exhibit B-1 Page 1 of 4
Certified to be a correct and true translation from the source text in Spanish to the target language English. 5 / APRIL / 2023 – PHILLIP BERRYMAN 

ATA-certified Spanish-English [ 432118] by Targem Translations Inc.

Proof of Claim Number: 31525

Claimant: Yolanda Rivera, Carmen

INFORMATION REQUESTED TO PROCESS YOUR CLAIM

Instructions

Please answer the five (5) questions and applicable sub-questions. Include as much detail as possible in your 

answers. Your answers should provide more information than is included in the initial proof of claim. 

As an example, if you previously wrote as the basis for your claim "Act 96," please now explain what specific 

laws you intend to base your claim on, the year in which the law in question was passed, and how and why 

you believe this particular law constitutes a basis for your claim.

In addition, if available and applicable to your claim, provide:

• A copy of the most recent brokerage statement, if your claim is based on bond ownership;

• A copy of an initial pleading, such as a Complaint or Answer, if your claim is based on pending 

litigation;

• An unpaid judgment, if obtained in connection with litigation, or settlement agreement;

• Written notice of your intent to file a claim with proof of mailing;

• Any and all documentation that, in your opinion, supports your claim.

Send the completed form and supporting documents by e-mail to PRClaimsInfo@primeclerk.com, or by 

mail or hand delivery to the following address:

Complementary information processing center of the 

Commonwealth of Puerto Rico 

c/o Prime Clerk LLC 

850 Third Avenue, Suite 412 

Brooklyn, NY 11232

Questionnaire

1. What is the basis of your claim?

□ A pending or concluded legal action with or against the Government of Puerto Rico

□ Current or former employment with the government of Puerto Rico

□ Other (please provide as much detail as possible. Attach additional pages if necessary).

[handwritten:] Puerto Rico Bonds

2. What is the amount of your claim (how much money do you claim you are owed):

[handwritten:] about 250,000.00

3. Bondholders: Does your claim relate to the ownership of bonds?

□ No. Skip to Question 4.

 Yes. CUSIP numbers of the bonds and amount claimed by CUSIP (if needed).

Batch 14 - Bond

Case:17-03283-LTS Doc#:23978-4 Filed:04/11/23 Entered:04/11/23 19:12:50 Desc:

Exhibit B-1 Page 2 of 4
Certified to be a correct and true translation from the source text in Spanish to the target language English. 5 / APRIL / 2023 – PHILLIP BERRYMAN ATAcertified Spanish-English [ 432118] by Targem Translations Inc.

Proof of Claim Number: 31525

Claimant'. Yolanda Rivera, Carmen

more space, attach an additional sheet):

CUISP AMOUNT CLAIMED

1 [handwritten:] CUSTPR1845SRf50401 [handwritten:] 167,184.00

2 [handwritten:] CUSTPR184 SRf 519 75 [handwritten:] 25,873.07

3 [handwritten:] Other UBS [handwritten:] 50,000.00 rejected

[handwritten:] Banco Popular [handwritten:] 10,000.00

4. Employment. Does your claim relate to current or former employment with the Puerto Rico government?

 No. Go to Question 5.

□ Yes. Answer questions 4(a)-(d).

4(a). Identify the specific agency or department in which you work or worked: 

4(b). Identify the dates of your employment in relation to your claim:

4(c). Last four digits of your social security number: 

4(d). What is the nature of your employment claims (select all that apply):

□ Retirement

□ Unpaid wages

□ Sick days

□ Complaint with the union

□ Vacations

□ Other (Provide as much detail as possible. Attach additional pages if necessary).

5. Legal action: Does your claim relate to a legal action already closed or pending?

No.

□ Yes. Answer Questions 5(a)-(f).

5(a). Identify the department or agency that is a party to this action.

Batch 14 - Bond

Case:17-03283-LTS Doc#:23978-4 Filed:04/11/23 Entered:04/11/23 19:12:50 Desc:

Exhibit B-1 Page 3 of 4
TRANSLATOR’S CERTIFICATE OF TRANSLATION

Translation from: Spanish (Puerto Rico) into English (US)

TARGEM Translations Inc.

I, PHILLIP BERRYMAN, ATA-certified Spanish-English #432118, acting as translator at TARGEM 

Translations Inc., a NEW YORK City corporation, with its principal office at 185 Clymer Street, Brooklyn, 

NY, 11211, USA, certify that:

the English translated document is a true and accurate translation of the original Spanish and has been 

translated to the best of my knowledge.

Original Document Name: 31525-Feb 9, 2022

 

 Signed this 5th day of April 2023

 

 

 Phillip Berryman

Case:17-03283-LTS Doc#:23978-4 Filed:04/11/23 Entered:04/11/23 19:12:50 Desc:

Exhibit B-1 Page 4 of 4