Official Form 204 Chapter 11 or Chapter 9 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 1 

Official Form 204 

Chapter 11 or Chapter 9 Cases: List of Creditors Who Have the 20 Largest 

Unsecured Claims and Are Not Insiders 12/15

A list of creditors holding the 20 largest unsecured claims must be filed in a Chapter 11 or Chapter 9 case. Include claims which the debtor 

disputes. Do not include claims by any person or entity who is an insider, as defined in 11 U.S.C. § 101(31). Also, do not include claims by 

secured creditors, unless the unsecured claim resulting from inadequate collateral value places the creditor among the holders of the 20 

largest unsecured claims. 

Name of creditor and complete 

mailing address, including zip code 

Name, telephone number, and 

email address of creditor 

contact 

Nature of the claim 

(for example, trade 

debts, bank loans, 

professional 

services, and 

government 

contracts)

Indicate if 

claim is 

contingent, 

unliquidated, 

or disputed 

Amount of unsecured claim 

If the claim is fully unsecured, fill in only unsecured 

claim amount. If claim is partially secured, fill in 

total claim amount and deduction for value of 

collateral or setoff to calculate unsecured claim. 

Total claim, if 

partially 

secured 

Deduction for 

value of 

collateral or 

setoff 

Unsecured 

claim 

1 

 

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 Check if this is an 

amended filing

Debtor name __________________________________________________________________ 

United States Bankruptcy Court for the: ______________________ District of _________ (State) 

Case number (If known): _________________________ 

 Fill in this information to identify the case: 

Dixie Centers LLC

Southern Florida

Fort Lauderdale Division

Maughan Himschoot & Admas

15750 New Hampshire Court

Suite A

Fort Meyers, FL 33908

Professional Fees for Debtor unliquidated

$12,821.00

CBR Law Group

165 East Palmetto Park Road

Suite 200

Boca raton, FL 33432

Professional Fees for Debtor unliquidated $5,500.00

Case 21-16276-PDR Doc 2 Filed 06/28/21 Page 1 of 2
Debtor _______________________________________________________ Case number (if known)_____________________________________ Name

Official Form 204 Chapter 11 or Chapter 9 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims page 2 

Name of creditor and complete 

mailing address, including zip code 

Name, telephone number, and 

email address of creditor 

contact 

Nature of the claim 

(for example, trade 

debts, bank loans, 

professional 

services, and 

government 

contracts)

Indicate if 

claim is 

contingent, 

unliquidated, 

or disputed 

Amount of unsecured claim 

If the claim is fully unsecured, fill in only unsecured 

claim amount. If claim is partially secured, fill in 

total claim amount and deduction for value of 

collateral or setoff to calculate unsecured claim. 

Total claim, if 

partially 

secured 

Deduction for 

value of 

collateral or 

setoff 

Unsecured 

claim 

9 

 

10 

 

11 

 

12 

 

13 

 

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15 

 

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19 

 

20 

 

Case 21-16276-PDR Doc 2 Filed 06/28/21 Page 2 of 2