Fill in this information to identify the case:

Debtor 1 Chance & Anthem, LLC

Debtor 2 

(Spouse, if filing)

United States Bankruptcy Court Southern District of Florida

Case number: 18−16248

FILED

U.S. Bankruptcy Court

Southern District of Florida

2/10/2020

Joseph Falzone, Clerk

Official Form 410

Proof of Claim 04/19

Read the instructions before filling out this form. This form is for making a claim for payment in a bankruptcy case. Do not use this form to

make a request for payment of an administrative expense. Make such a request according to 11 U.S.C. § 503.

Filers must leave out or redact information that is entitled to privacy on this form or on any attached documents. Attach redacted copies of any

documents that support the claim, such as promissory notes, purchase orders, invoices, itemized statements of running accounts, contracts, judgments,

mortgages, and security agreements. Do not send original documents; they may be destroyed after scanning. If the documents are not available,

explain in an attachment.

A person who files a fraudulent claim could be fined up to $500,000, imprisoned for up to 5 years, or both. 18 U.S.C. §§ 152, 157, and 3571.

Fill in all the information about the claim as of the date the case was filed. That date is on the notice of bankruptcy (Form 309) that you received.

 Part 1: Identify the Claim

1.Who is the current

creditor?

Jeffrey M. Siskind

Name of the current creditor (the person or entity to be paid for this claim)

Other names the creditor used with the debtor

2.Has this claim been

acquired from

someone else?

No

Yes. From whom?

3.Where should notices

and payments to the

creditor be sent?

Federal Rule of

Bankruptcy Procedure

(FRBP) 2002(g)

Where should notices to the creditor be sent? Where should payments to the creditor be sent? (if

different)

Jeffrey M. Siskind 

Name Name

3465 Santa Barbara Drive

Wellington, FL 33414

Contact phone 561−791−9565 Contact phone

Contact email jeffsiskind@msn.com Contact email

Uniform claim identifier for electronic payments in chapter 13 (if you use one):

4.Does this claim amend

one already filed?

No

Yes. Claim number on court claims registry (if known) Filed on

MM / DD / YYYY

5.Do you know if anyone

else has filed a proof

of claim for this claim?

No

Yes. Who made the earlier filing?

Official Form 410 Proof of Claim page 1

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 Part 2: Give Information About the Claim as of the Date the Case Was Filed

6.Do you have any

number you use to

identify the debtor?

No

Yes. Last 4 digits of the debtor's account or any number you use to identify the debtor:

7.How much is the

claim?

$ 42500.00 Does this amount include interest or other charges?

No

Yes. Attach statement itemizing interest, fees, expenses, or

other charges required by Bankruptcy Rule 3001(c)(2)(A).

8.What is the basis of

the claim?

Examples: Goods sold, money loaned, lease, services performed, personal injury or wrongful

death, or credit card. Attach redacted copies of any documents supporting the claim required by

Bankruptcy Rule 3001(c).

Limit disclosing information that is entitled to privacy, such as healthcare information.

Legal work pertaining to cannabis licensing fro which Claimant was not

remunerated.

9. Is all or part of the

claim secured?

No

Yes. The claim is secured by a lien on property.

Nature of property:

Real estate. If the claim is secured by the debtor's principal residence, file a Mortgage

Proof of Claim Attachment (Official Form 410−A) with this Proof of Claim.

Motor vehicle

Other. Describe: Unrecorded attorney's charging lien

Basis for perfection: Quantum meruit 

Attach redacted copies of documents, if any, that show evidence of perfection of a security

interest (for example, a mortgage, lien, certificate of title, financing statement, or other

document that shows the lien has been filed or recorded.)

Value of property: $ 

Amount of the claim that is

secured:

$ 42500.00 

Amount of the claim that is

unsecured:

$ 0.00 (The sum of the secured and

unsecured amounts should

match the amount in line 7.)

Amount necessary to cure any default as of the

date of the petition:

$ 42500.00 

Annual Interest Rate (when case was filed) 0 %

Fixed

Variable

10.Is this claim based on

a lease?

No

Yes. Amount necessary to cure any default as of the date of the petition.$

11.Is this claim subject to

a right of setoff?

No

Yes. Identify the property:

Official Form 410 Proof of Claim page 2

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12.Is all or part of the claim

entitled to priority under

11 U.S.C. § 507(a)?

No

Yes. Check all that apply: Amount entitled to priority

A claim may be partly

priority and partly

nonpriority. For example,

in some categories, the

law limits the amount

entitled to priority.

Domestic support obligations (including alimony and child support)

under 11 U.S.C. § 507(a)(1)(A) or (a)(1)(B).

$

Up to $3,025* of deposits toward purchase, lease, or rental of

property or services for personal, family, or household use. 11

U.S.C. § 507(a)(7).

$

Wages, salaries, or commissions (up to $13,650*) earned within

180 days before the bankruptcy petition is filed or the debtor's

business ends, whichever is earlier. 11 U.S.C. § 507(a)(4).

$

Taxes or penalties owed to governmental units. 11 U.S.C. §

507(a)(8).

$

Contributions to an employee benefit plan. 11 U.S.C. § 507(a)(5). $

Other. Specify subsection of 11 U.S.C. § 507(a)( ) that applies $

* Amounts are subject to adjustment on 4/1/22 and every 3 years after that for cases begun on or after the date

of adjustment.

 Part 3: Sign Below

The person completing

this proof of claim must

sign and date it. FRBP

9011(b).

If you file this claim

electronically, FRBP

5005(a)(2) authorizes courts

to establish local rules

specifying what a signature

is.

A person who files a

fraudulent claim could be

fined up to $500,000,

imprisoned for up to 5

years, or both.

18 U.S.C. §§ 152, 157 and

3571.

Check the appropriate box:

I am the creditor.

I am the creditor's attorney or authorized agent.

I am the trustee, or the debtor, or their authorized agent. Bankruptcy Rule 3004.

I am a guarantor, surety, endorser, or other codebtor. Bankruptcy Rule 3005.

I understand that an authorized signature on this Proof of Claim serves as an acknowledgment that when calculating

the amount of the claim, the creditor gave the debtor credit for any payments received toward the debt.

I have examined the information in this Proof of Claim and have a reasonable belief that the information is true

and correct.

I declare under penalty of perjury that the foregoing is true and correct.

Executed on date 2/10/2020

MM / DD / YYYY

/s/ Jeffrey M. Siskind 

Signature

Print the name of the person who is completing and signing this claim:

Name Jeffrey M. Siskind 

First name Middle name Last name

Title Attorney 

Company Siskind Legal, PLLC 

Identify the corporate servicer as the company if the authorized agent is a

servicer

Address 3465 Santa Barbara Drive 

Number Street

 Wellington, FL 33414 

City State ZIP Code

Contact phone 561−7941−9565 Email jeffsiskind@msn.com

Official Form 410 Proof of Claim page 3

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