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BAKER 

&

HOSTETLER LLP

ATTORNEYS AT LAW

SAN FRANCISCO

EXHIBIT A 

REVISED FIRE PROOF OF CLAIM FORM 

Case: 19-30088 Doc# 2605-1 Filed: 06/19/19 Entered: 06/19/19 09:39:18 Page 1

of 7
UNITED STATES BANKRUPTCY COURT FOR 

THE NORTHERN DISTRICT OF CALIFORNIA 

SAN FRANCISCO DIVISION 

In re: 

PG&E Corporation, and 

Pacific Gas and Electric Company, 

Debtors. 

Chapter 11 

Case No. 19-30088 (DM) 

Jointly Administered 

Proof of Claim (Fire Claim Related) 

Read the instructions before filing this claim form. This form is for tort claimants who have a claim against the Debtors (i.e. PG&E 

Corporation and Pacific Gas and Electric Company) that arose prior to the Debtors filing for bankruptcy (i.e. prior to January 29, 2019) and 

that arose from, or relates to, a fire. Do not use this form for non-fire claims. Non-fire tort claimants should use Form 410. 

Do NOT file a fraudulent claim. 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. 

Please type or print in the spaces below. Do NOT use red ink or pencil. 

Identify the Claim 

1. Who is the current 

creditor? 

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

2. Are you filing on behalf 

of your family? 

A family is a group of two 

or more people related by 

birth, marriage, domestic 

partnership, or adoption 

and residing together. All 

such people are 

considered as members 

of one family. 

 Yes 

 No 

 

 If you checked “Yes”, please provide the full name of each family member that you are filing on behalf of: 

 __________________________________________ 

 __________________________________________ 

__________________________________________ 

__________________________________________ 

3. Where should notices 

and payments to the 

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

creditor be sent? Name ______________________________________________ Name _____________________________________________________ 

Federal Rule of Attorney Name (if applicable) ____________________________ Attorney Name (if applicable) ___________________________________ 

Bankruptcy Procedure Attorney Bar Number (if applicable) _______________________ Attorney Bar Number (if applicable) ______________________________

(FRBP) 2002(g) Street Address _______________________________________ Street Address ______________________________________________ 

City ________________________________________________ City _______________________________________________________ 

State _______________________________________________ State ______________________________________________________ 

Zip Code ____________________________________________ Zip Code ___________________________________________________ 

Phone Number _______________________________________ Phone Number ______________________________________________ 

Email Address ________________________________________ Email Address _______________________________________________ 

4. Does this claim amend 

one already filed? 

 No 

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

MM / DD / YYYY 

Give Information About the Claim as of the Date the Case Was Filed 

5. What fire is the basis of 

your claim? Check all 

that apply. 

 Camp Fire (2018) 

 North Bay Fires (2017) 

 Ghost Ship Fire (2016) 

 Butte Fire (2015) 

 Other (please provide date and brief description of fire): ________________________________________________ 

_________________________________________________________________________________________________ 

Part 1: 

Part 2: 

Case: 19-30088 Doc# 2605-1 Filed: 06/19/19 Entered: 06/19/19 09:39:18 Page 2

of 7
Part 3: 

The person completing Check the appropriate box: 

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. 





I am the creditor. 

I am the creditor’s attorney or authorized agent. 

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 

MM / DD / YYYY 

Signature 

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

6. What are the loss 

location(s) where you 

and/or your family 

suffered harm? (e.g. 

home or business 

address, place of injury, 

place from which you 

were evacuated, if 

different). 

 Location(s): 

 

7. How were you and/or 

your family harmed? 

Check all that apply. 

 Property Damage (homes, structures, personal property, land, trees, landscaping, and all other property damage) 

 Owner  Renter  Occupant  Other (Please specify): 

 Personal Injury 

 Wrongful Death (If checked, please provide the name of the deceased: 

 Business Loss/Interruption 

 Lost wages and earning capacity 

 Loss of community and essential services 

 Agricultural loss 

 Other (Please specify) 

8. What damages are you 

and/or your family 

claiming/seeking? 

 Economic damages (including replacement cost of damaged property, diminution in value, loss of use, lost inventory, lost 

profits, and other economic damage) 

 Non-economic damages (including loss of society and support, loss of consortium, pain and suffering, emotional distress, 

annoyance and discomfort, and other non-economic damage) 

 Punitive, exemplary, and statutory damages 

 Attorney’s fees and litigation costs 

 Interest 

 Any and all other damages recoverable under California law 

 Other (Please specify) 

9. How much is the claim?  To be determined in an amount according to proof 

Sign Below 

Name _____________________________________________________________________________________ 

First Name Middle Name Last Name 

Title _____________________________________________________________________________________ 

Company _____________________________________________________________________________________ 

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

Address _____________________________________________________________________________________ 

Number Street 

_____________________________________________________________________________________ 

City State ZIP Code 

Contact phone _____________________________________________ Email _____________________________ Case: 19-30088 Doc# 2605-1 Filed: 06/19/19 Entered: 06/19/19 09:39:18 Page 3

of 7
Instructions for Proof of 

Claim (Fire Claim Related) 

United States Bankruptcy Court 

You may have a claim against the Debtors for monetary 

loss, personal injury (including death), or other asserted 

damages arising out of or related to a fire. You should 

consider obtaining the advice of an attorney, especially 

if you are unfamiliar with the bankruptcy process and 

privacy regulations.

How to fill out this form: 

 Fill in all of the information about the claim as of 

the date this claim form is filed.

 If the claim has been acquired from someone else, 

then state the identity of the last party who owned the 

claim or was the holder of the claim and who transferred 

it to you before the initial claim was filed. 

 For a minor child, fill in only the child’s initials and 

the full name of the child’s parent or guardian. For 

example, write A.B., a minor child (John Doe, parent). 

See Bankruptcy Rule 9037. 

 You are not required to attach supporting 

documents to this form. Many communities suffered 

significant, if not complete, ruin and destruction. Also, 

many individual claimants are displaced, lack the means 

for electronic and comprehensive communications and 

continue to have urgent priorities that make 

documentation requirements difficult and impractical. It 

is understood that supporting documents for many 

claimants have been destroyed or lost in the fires and 

that the reconstruction and retrieval process is slow or 

even underway. Supporting documents shall be 

gathered, maintained and provided at a later date as 

instructed by the Court. 

 Question 2. Members of a family are not required to file 

a proof of claim as a family but can submit individual 

claim forms for each family member that has a tort claim 

against the debtors. 

 Question 6. If you suffered property damage, then 

provide the street address of each real property parcel 

where you suffered property damage. If you were 

personally evacuated as the result of a fire, then provide 

the address or intersection closest to where you 

encountered the fire and began evacuation. If you 

suffered property damage and were evacuated from a 

different location, include both. If you were a renter, 

provide the address of your residence. 

 Question 7. This question requests general statements 

of underlying facts relating to harm and is not intended to 

be exhaustive or preclusive. 

Confirmation that the claim has been filed 

To receive confirmation that the claim has been filed, enclose a 

stamped self-addressed envelope and a copy of this form. You may 

view a list of filed claims in this case by visiting the Claims and 

Noticing Agent’s website at http://restructuring.primeclerk.com/pge. 

Understand the terms used in this form 

Claim: A creditor’s right to receive payment for a debt that the debtor 

owed on the date the debtor filed for bankruptcy. 11 U.S.C. § 101 (5). 

A claim may be secured or unsecured.

Creditor: A person, corporation, or other entity to whom a debtor 

owes a debt that was incurred on or before the date the debtor filed 

for bankruptcy. 11 U.S.C. § 101 (10). 

Debtor: PG&E Corporation and Pacific Gas & Electric Company. 

Information that is entitled to privacy: A Proof of Claim form must 

show only the last 4 digits of any social security number, an 

individual’s tax identification number, or a financial account number, 

only the initials of a minor’s name, and only the year of any person’s 

date of birth. If a claim is based on delivering health care goods or 

services, limit the disclosure of the goods or services to avoid 

embarrassment or disclosure of confidential health care information. 

You may later be required to give more information if the trustee or 

someone else in interest objects to the claim. 

Proof of Claim: A form that shows the creditor has a tort claim 

against the debtors on or before the date of the bankruptcy filing. The 

form must be filed in the district where the case is pending.

Redaction of information: Masking, editing out, or deleting certain 

information to protect privacy. Filers must redact or leave out 

information entitled to privacy on the Proof of Claim form and any 

attached documents. 

Offers to purchase a claim 

Certain entities purchase claims for an amount that is less than the 

face value of the claims. These entities may contact creditors offering 

to purchase their claims. Some written communications from these 

entities may easily be confused with official court documentation or 

communications from the debtor. These entities do not represent the 

bankruptcy court, the bankruptcy trustee, or the debtor. A creditor 

has no obligation to sell its claim. However, if a creditor decides to 

sell its claim, any transfer of that claim is subject to Bankruptcy Rule 

3001(e), any provisions of the Bankruptcy Code (11 U.S.C. § 101 et 

seq.) that apply, and any orders of the bankruptcy court that apply. 

Please send completed Proof(s) of Claim to: 

PG&E Corporation Claims Processing Center c/o Prime Clerk LLC

850 3rd Avenue, Suite 412 

Brooklyn, NY 11232

Do not file these instructions with your 

form. 

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. 

Case: 19-30088 Doc# 2605-1 Filed: 06/19/19 Entered: 06/19/19 09:39:18 Page 4

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Case: 19-30088 Doc# 2605-1 Filed: 06/19/19 Entered: 06/19/19 09:39:18 Page 7

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