Weil, Gotshal & Manges LLP 

767 Fifth Avenue 

New York, NY 10153-0119

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Exhibit A-2

Fire Claimant Proof of Claim Form

Case: 19-30088 Doc# 2806-2 Filed: 07/01/19 Entered: 07/01/19 14:01:13 Page 1

of 6
 Proof of Claim (Fire 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 (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. Has this claim been

acquired from

someone else?

 No 

 Yes. From whom? 

3. Are you filing this claim 

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. 

 No

 Yes

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

behalf of: 

 

 

4. 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_____________________________________________________________ 

Attorney Name (if applicable)__________________________________________ 

Attorney Bar Number (if applicable)_____________________________________ 

Street Address______________________________________________________

City______________________________________________________________ 

State_____________________________________________________________ 

Zip Code__________________________________________________________ 

Phone Number_____________________________________________________ 

Email Address______________________________________________________ 

Name____________________________________________________________ 

Attorney Name (if applicable)_________________________________________ 

Attorney Bar Number (if applicable)_____________________________________ 

Street Address_____________________________________________________ 

City______________________________________________________________ 

State____________________________________________________________ 

Zip Code_________________________________________________________ 

Phone Number_____________________________________________________ 

 Email Address____________________________________________________

5. Does this claim amend

one already filed?

 No 

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

MM / DD / YYYY 

6. 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# 2806-2 Filed: 07/01/19 Entered: 07/01/19 14:01:13 Page 2

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 Proof of Claim (Fire Related) Page 2

Part 2: Give Information About the Claim as of the Date this Claim Form is Filed 

7. 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: 

 

8. 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): 

 

9. 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): 

10. What damages are you 

and/or your family 

claiming/seeking? 

Check all that apply 

 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): 

11. How much is the claim?

 $ (optional)

 Unknown / To be determined at a later date 

   

Case: 19-30088 Doc# 2806-2 Filed: 07/01/19 Entered: 07/01/19 14:01:13 Page 3

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 Proof of Claim (Fire Related) Page 3

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 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# 2806-2 Filed: 07/01/19 Entered: 07/01/19 14:01:13 Page 4

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Proof of Claim Instructions (Fire Related) Page 1

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 chapter 

11 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 may but are not required to attach supporting 

documents to this form. 

Supporting documents will be gathered, maintained, and 

provided at a later date as instructed by the Court. If you do

attach documents, you should attach redacted documents as 

supporting documentation will be made publicly available 

and will not be kept confidential. See the definition of 

redaction of information below. 

 Do not attach original documents because 

attachments may be destroyed after scanning.

 Question 3. Members of a family may but are not 

required to file a proof of claim as a family but may, if 

they choose, submit individual claim forms for each 

family member that has a claim against the debtors.

 Question 9. 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 10. This question requests general statements of 

underlying facts relating to harm and is not intended to be 

exhaustive or preclusive. 

 Question 11. You are not required to include a claim 

amount with your proof of claim. Providing a claim 

amount at this time is optional. 

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 

together with the original. 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. 

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# 2806-2 Filed: 07/01/19 Entered: 07/01/19 14:01:13 Page 5

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Proof of Claim Instructions (Fire Related) Page 2

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. In this instance, PG&E Corporation and Pacific Gas 

& Electric Company. 

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. 

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

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

(in these cases, January 29, 2019). 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:

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 

(beginning July 15, 2019 through the Bar Date (October 21, 

2019) during the hours of 8:30 a.m. – 5:00 p.m. Prevailing 

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 photocopy of your Proof 

of Claim if you wish to receive a date-stamped copy. 

Do not file these instructions with your form

Case: 19-30088 Doc# 2806-2 Filed: 07/01/19 Entered: 07/01/19 14:01:13 Page 6

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