B 210 A (Form 210 A) (12/ )

UNITED STATES BANKRUPTCY COURT

__________ District Of __________

In re ________________________________, Case No. ________________

TRANSFER OF CLAIM OTHER THAN FOR SECURITY

A CLAIM HAS BEEN FILED IN THIS CASE or deemed filed under 11 U.S.C. § 1111(a). Transferee

hereby gives evidence and notice pursuant to Rule 3001(e)(2), Fed. R. Bankr. P., of the transfer, other

than for security, of the claim referenced in this evidence and notice.

______________________________________ ____________________________________

Name of Transferee Name of Transferor

Name and Address where notices to transferee Court Claim # (if known):

should be sent: Amount of Claim:

Date Claim Filed:

Phone: ______________________________ Phone:

Last Four Digits of Acct #: ______________ Last Four Digits of Acct. #: __________

Name and Address where transferee payments

should be sent (if different from above): 

Phone:

Last Four Digits of Acct #:

I declare under penalty of perjury that the information provided in this notice is true and correct to the

best of my knowledge and belief.

By:__________________________________ Date:____________________________

Transferee/Transferee’s Agent

Penalty for making a false statement: Fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §§ 152 & 3571.

 Northern District of California

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B 210 A (Form 210 A) (12/ )

UNITED STATES BANKRUPTCY COURT

__________ District Of __________

In re ________________________________, Case No. ________________

TRANSFER OF CLAIM OTHER THAN FOR SECURITY

A CLAIM HAS BEEN FILED IN THIS CASE or deemed filed under 11 U.S.C. § 1111(a). Transferee

hereby gives evidence and notice pursuant to Rule 3001(e)(2), Fed. R. Bankr. P., of the transfer, other

than for security, of the claim referenced in this evidence and notice.

______________________________________ ____________________________________

Name of Transferee Name of Transferor

Name and Address where notices to transferee Court Claim # (if known):

should be sent: Amount of Claim:

Date Claim Filed:

Phone: ______________________________ Phone:

Last Four Digits of Acct #: ______________ Last Four Digits of Acct. #: __________

Name and Address where transferee payments

should be sent (if different from above): 

Phone:

Last Four Digits of Acct #:

I declare under penalty of perjury that the information provided in this notice is true and correct to the

best of my knowledge and belief.

By:__________________________________ Date:____________________________

Transferee/Transferee’s Agent

Penalty for making a false statement: Fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §§ 152 & 3571.

 Northern District of California

Case: 19-30088 Doc# 2494 Filed: 06/12/19 Entered: 06/12/19 10:36:14 Page 3 of

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6
B 210 A (Form 210 A) (12/ )

UNITED STATES BANKRUPTCY COURT

__________ District Of __________

In re ________________________________, Case No. ________________

TRANSFER OF CLAIM OTHER THAN FOR SECURITY

A CLAIM HAS BEEN FILED IN THIS CASE or deemed filed under 11 U.S.C. § 1111(a). Transferee

hereby gives evidence and notice pursuant to Rule 3001(e)(2), Fed. R. Bankr. P., of the transfer, other

than for security, of the claim referenced in this evidence and notice.

______________________________________ ____________________________________

Name of Transferee Name of Transferor

Name and Address where notices to transferee Court Claim # (if known):

should be sent: Amount of Claim:

Date Claim Filed:

Phone: ______________________________ Phone:

Last Four Digits of Acct #: ______________ Last Four Digits of Acct. #: __________

Name and Address where transferee payments

should be sent (if different from above): 

Phone:

Last Four Digits of Acct #:

I declare under penalty of perjury that the information provided in this notice is true and correct to the

best of my knowledge and belief.

By:__________________________________ Date:____________________________

Transferee/Transferee’s Agent

Penalty for making a false statement: Fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §§ 152 & 3571.

 Northern District of California

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