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Weil, Gotshal & Manges LLP 

767 Fifth Avenue 

New York, NY 10153-0119

Exhibit C-2

Wildfire Claimant Proof of Claim Form

Case: 19-30088 Doc# 1784-6 Filed: 05/01/19 Entered: 05/01/19 15:32:50 Page 1

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Proof of Claim (Wildfire Related) Page 1

Part 1:

UNITED STATES BANKRUPTCY COURT 

NORTHERN DISTRICT OF CALIFORNIA (SAN FRANCISCO DIVISION)

In re: 

PG&E CORPORATION, 

- and - 

PACIFIC GAS AND ELECTRIC 

COMPANY, 

 Debtors.

Bankruptcy Case 

No. 19-30088 (DM) 

Chapter 11 

(Lead Case) 

(Jointly Administered)

Proof of Claim (Wildfire Related) 

Read the instructions before filling out this form. This form is for asserting general unsecured claims based on damages or losses resulting 

from a wildfire. 

Do not use this form to assert any other pre-petition claims, including secured claims or claims entitled to priority under 11 U.S.C. 

§ 507(a). Secured claims, claims entitled to priority under 11 U.S.C. § 507(a) and non-wildfire related claims should be filed on Form 

410, available on https://restructuring.primeclerk.com/pge. 

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. 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 January 29, 2019, except where otherwise specified.

Identify the Claim 

1. Who is the current

creditor?

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

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

different)

creditor be sent?

Federal Rule of

Bankruptcy Procedure

(FRBP) 2002(g) 

Name 

 

Number Street 

City State ZIP Code 

Contact phone 

Contact email 

Name 

Number Street 

City State ZIP Code 

Contact phone 

Contact email 

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? 

Case: 19-30088 Doc# 1784-6 Filed: 05/01/19 Entered: 05/01/19 15:32:50 Page 2

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Proof of Claim (Wildfire Related) Page 2

Part 3:

Part 2: Attorney Information (Optional) 

6. Who represents you 

in this matter?

Who represents you in this matter?

You do not need an 

attorney to file this 

form 

 

Law Firm Name 

 

Attorney Name 

 

Number Street 

City State ZIP Code 

Contact phone Contact email 

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

7. Which fire is relevant to 

your claim?

Please select one fire 

per claim form. If you 

have separate claims for 

multiple events, please 

submit a separate claim 

for each event. 

 37 

 Adobe 

 Atlas 

 Blue 

 Butte 

 Camp 

 Cascade 

 Cherokee 

 Honey 

 La Porte 

 Lobo 

 Maacama 

 McCourtney 

 Norrbom 

 Nuns 

 Partrick 

 Pocket 

 Point 

 Pressley 

 Pythian (a.k.a Oakmont) 

 Redwood 

 Sulphur 

 Tubbs 

 Unknown 

 Other: _________________________ 

   

Case: 19-30088 Doc# 1784-6 Filed: 05/01/19 Entered: 05/01/19 15:32:50 Page 3

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Proof of Claim (Wildfire Related) Page 3

Part 3 (continued):

  

8. Is all or part of the claim

based on property 

owned or rented and 

was affected by the 

2017 or 2018 fires? 

 Note: It is unlawful to 

engage in insurance 

fraud in the State of 

California. Insurance 

fraud includes knowingly 

presenting multiple claims 

for the same loss or injury 

with an intent to defraud. 

See Cal. Penal Code § 

550. 

 No 

 Yes. This is a property-related claim. As to each of the categories of claims set forth below, attach copies of the 

documents supporting the claim, such as proof of ownership (titles, deeds), property appraisals, insurance documents 

or lease/rental agreements and complete below for each property related claim types that apply (Loss of 

Residence/Structure Claim, Personal Property Claim, Other Property Claim). 

 Loss of Residence/Structure Claim 

Property Address: 

 

Do you intend to rebuild?

 No. 

 Yes.

How much is the claim? $ or 

 Unknown 

Was the property on the market for sale at the time of the fire?

 No. 

 Yes. What was the asking price? $ 

 Personal Property Claim 

Type of Property:

 Personal contents (e.g., furniture, appliances) 

 Business contents (e.g., fixtures, equipment) 

 Auto/Motor Vehicle 

 Other. Describe: 

How much is the claim? $ or 

 Unknown 

 Other Property Claim 

Please Describe the Property:

________ 

How much is the claim? $ or 

 Unknown 

Is (Are) the above claim(s) covered by insurance?

 No. 

 Yes. Fill out the information below. 

Who is (are) the insurance company(ies)? 

 

What property (e.g., structure, personal 

property, other) is(are) covered by insurance)? 

 

What is the total amount of insurance 

coverage with respect to this (these) 

property-related claim(s)? $ 

How much in insurance proceeds, if any, 

have you received (to date) with respect 

to this (these) property-related claim(s)? $ 

    Case: 19-30088 Doc# 1784-6 Filed: 05/01/19 Entered: 05/01/19 15:32:50 Page 4

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Proof of Claim (Wildfire Related) Page 4

Part 3 (continued):

9. Is all or part of the claim

based on business/ 

economic loss? (e.g., 

lost profits, lost wages, 

loss of goodwill) 

 Note: It is unlawful to 

engage in insurance 

fraud in the State of 

California. Insurance 

fraud includes knowingly 

presenting multiple claims 

for the same loss or injury 

with an intent to defraud. 

See Cal. Penal Code § 

550.

 No 

 Yes. This is a business/economic loss claim. Attach copies of the documents supporting the claim, such as proof of 

operation at time of fire, federal tax returns for the two years preceding the fire, monthly/annual profit and loss 

statements or W-9 forms, and complete below. 

Name of Business: 

Business Address: 

How much is the claim? $ or 

 Unknown 

Basis of claim:

________ 

Is the claim covered by insurance?

 No. 

 Yes. Fill out the information below. 

Who is the insurance company? 

What is the total amount of insurance 

coverage with respect to this claim? $ 

How much in insurance proceeds, if any, 

have you received (to date) with respect 

to this claim? $ 

10. Is all or part of the claim

based on wrongful 

death? 

 No 

 Yes. This is a wrongful death claim. Attach copies of the documents supporting the claim, such as identifying 

information (U.S. passport, driver’s license), death certificate, copy of autopsy findings or insurance benefit 

summaries, and complete below. 

Decedent name: 

Creditor’s relationship to Decedent: 

   

Case: 19-30088 Doc# 1784-6 Filed: 05/01/19 Entered: 05/01/19 15:32:50 Page 5

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Proof of Claim (Wildfire Related) Page 5

Part 3 (continued):

11. Is all or part of the claim

based on personal 

injury? (e.g., physical 

injury, emotional distress) 

 Note: It is unlawful to 

engage in insurance 

fraud in the State of 

California. Insurance 

fraud includes knowingly 

presenting multiple claims 

for the same loss or injury 

with an intent to defraud. 

See Cal. Penal Code § 

550.

 No 

 Yes. This is a personal injury claim. Attach copies of any documents supporting this claim, such as hospital records 

reflecting date and nature of injury, physician office visit records or insurance benefit summaries, and complete below. 

Injured Name: 

Where was the injured person 

located when the injury occurred? 

When the injury occurred (for claims asserting emotional distress, 

please also include estimated date and time of injury) 

How much is the claim? $ or 

 Unknown 

Nature of the injury:

________ 

Is the claim covered by insurance?

 No. 

 Yes. Fill out the information below. 

Who is the insurance company? 

What is the total amount of insurance 

coverage with respect to this claim? $ 

How much in insurance proceeds, if any, 

have you received (to date) with respect 

to this claim? $ 

12. Is all or part of the claim

based on any other 

reason not listed in 

questions 8 through 11 

above? 

 Note: It is unlawful to 

engage in insurance 

fraud in the State of 

California. Insurance 

fraud includes knowingly 

presenting multiple claims 

for the same loss or injury 

with an intent to defraud. 

See Cal. Penal Code § 

550.

 No 

 Yes. Attach copies of any documents supporting this claim, and complete below. 

How much is the claim? $ or 

 Unknown 

Basis of Claim:

________ 

Is the claim covered by insurance?

 No. 

 Yes. Fill out the information below. 

Who is the insurance company? 

What is the total amount of insurance 

coverage with respect to this claim? $ 

How much in insurance proceeds, if any, 

have you received (to date) with respect 

to this claim? $ 

   

Case: 19-30088 Doc# 1784-6 Filed: 05/01/19 Entered: 05/01/19 15:32:50 Page 6

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Proof of Claim (Wildfire Related) Page 6

Part 4: 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 _______ (mm/dd/yyyy) 

 

Signature 

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

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# 1784-6 Filed: 05/01/19 Entered: 05/01/19 15:32:50 Page 7

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Proof of Claim Instructions (Wildfire Related) Page 1

Instructions for Proof of Claim (Wildfire Related) 

United States Bankruptcy Court 

These instructions and definitions generally explain the law. In certain circumstances, such as bankruptcy cases that debtors do 

not file voluntarily, exceptions to these general rules may apply. 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 

January 29, 2019.

 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. 

 Attach any supporting documents to this form.

Attach redacted copies of any documents that show that the

debt exists, a lien secures the debt, or both. (See the

definition of redaction on the next page.) 

 Do not attach original documents because 

attachments may be destroyed after scanning.

 If the claim is based on delivering health care goods 

or services, do not disclose confidential health care 

information. Leave out or redact confidential 

information both in the claim and in the attached 

documents.

 A Proof of Claim form and any attached documents 

must show only the last 4 digits of any social security 

number, individual’s tax identification number, or 

financial account number, and only the year of any 

person’s date of birth. See Bankruptcy Rule 9037. 

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

the full name and address of the child’s parent or 

guardian. For example, write A.B., a minor child (John

Doe, parent, 123 Main St., City, State). See Bankruptcy

Rule 9037. 

Confirmation that the claim has been filed

To receive confirmation that the claim has been filed, either 

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

https://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: A person, corporation, or other entity who is in

bankruptcy. Use the debtor’s name and case number as shown in 

the bankruptcy notice you received. 11 U.S.C. § 101 (13). 

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

and any attached documents 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. 

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# 1784-6 Filed: 05/01/19 Entered: 05/01/19 15:32:50 Page 8

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Proof of Claim Instructions (Wildfire Related) Page 2

Proof of claim: A form that shows the amount of debt the

debtor owed to a creditor on 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. 

Secured claim under 11 U.S.C. § 506(a): A claim backed by

a lien on particular property of the debtor. A claim is secured

to the extent that a creditor has the right to be paid from the

property before other creditors are paid. The amount of a

secured claim usually cannot be more than the value of the

particular property on which the creditor has a lien. Any

amount owed to a creditor that is more than the value of the

property normally may be an unsecured claim. But exceptions

exist; for example, see 11 U.S.C. § 1322(b) and the final

sentence of § 1325(a). 

Examples of liens on property include a mortgage on real

estate or a security interest in a car. A lien may be voluntarily

granted by a debtor or may be obtained through a court

proceeding. In some states, a court judgment may be a lien. 

Unsecured claim: A claim that does not meet the

requirements of a secured claim. A claim may be unsecured in

part to the extent that the amount of the claim is more than the

value of the property on which a creditor has a lien. 

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:

If by first class mail: 

PG&E Corporation Claims Processing Center 

c/o Prime Clerk LLC 

Grand Central Station, PO Box 4850 

New York, NY 10163-4850 

If by overnight courier or hand delivery: 

PG&E Corporation Claims Processing Center 

c/o Prime Clerk LLC 

850 Third Avenue, Suite 412 

Brooklyn, NY 11232

You may also hand deliver your completed Proof(s) of 

Claim to any of the following service center offices (during 

the hours of 8:30 a.m. – 5:00 p.m. Pacific Time): 

Chico Service Center 

350 Salem Street 

Chico, CA 95928 

Marysville Service Center 

231 “D” Street 

Marysville, CA 95901 

Napa Service Center 

1850 Soscol Ave. Ste 105 

Napa, CA 94559 

Oroville Service Center 

1567 Huntoon Street 

Oroville, CA 95965 

Redding Service Center 

3600 Meadow View Road 

Redding, CA 96002 

Santa Rosa Service Center 

111 Stony Circle 

Santa Rosa, CA 95401 

Photocopy machines will not be available at the Claim 

Service Centers; you must bring a copy of your claim if you 

wish to receive a date-stamped conformed copy. 

Do not file these instructions with your form

Case: 19-30088 Doc# 1784-6 Filed: 05/01/19 Entered: 05/01/19 15:32:50 Page 9

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