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BAKER 

&

HOSTETLER LLP

ATTORNEYS AT LAW

SAN FRANCISCO

EXHIBIT C 

CAL OES CLAIMS

Case: 19-30088 Doc# 5096-3 Filed: 12/12/19 Entered: 12/12/19 15:58:14 Page 1

of 10
Claim Number: 87748

United States Bankruptcy Court, Northern District of California 

r,11 ,n :hs , 1•op11111c,n to 1elc111,ty tl,c c~,c (Select only c,ne Debtor pr, cl~,m forrn;. 

D PG&E Corporation (19-30088) 

IZJ Pacific Gas and Electric Company (19-30089) 

Official Form 410 

Proof of Claim 

RECEIVED 

NOV 15 2019 

04/16 

Read the lostructlons before fllllng out this fonn. This fonn Is for making a claim for paymont In a bankruptcy case. Do not use this fonn to 

make a requ.t for payment of an admlni.tratlve expense. Make such a requNt according to 11 U.S.C. § 503. 

Fllors must leave out or redact lnfonnaUon that is entitled lo prtvacy on this form or on any attached documents. Attach redacted copies of any 

documents that ~port the claim, such as pronissory notes, pU"chase order&, Invoices, ltemlzed statements-of running accounts, contracts, Judgments, 

mortgages. and security agreements. Do not send original documents; they may be destroyed after scanning. If the documeots are not available, 

explain in an attachment. 

A peraon Y.tio files a fraudulent claim colM:I be fined up to $500,000, imprisoned for up to 5 years, or both. 18 U.S.C. §§ 152, 157, and 3571. 

FIii in all the Information about the ctalm as of the date the case was flied. That date Is on the notice of bankruptcy (Form 309) that you received. 

ld ... tlfy the Claim 

1. Who ls the current 

creditor? 

2. Has this claim been 

acquired from 

someone else? 

3. Where should noUces 

and paynwnts to the 

creditor be sent? 

Federal Rule of 

Bankruptcy Procedure 

(FRBP) 2002(9) 

California Govenor's Office of Emergency Services 

Name of the c,men( cnditor (the parson or entily to be paid for this claim) 

Olhor oames the creditor used w~h the debtor C_a_l_O_E_S ____________________ _ 

fii1 No 

:J Yes. From whom? _ __________ ________________ _ _ 

Where should notices to the credilor be sent? 

CALIFORNIA DEPARTMENT OF JUSTICE 

OFFICE OF THE ATTORNEY GENERAL 

Matthew C. Heyn, Deputy Attorney General 

300 South Spring Street, Suite 1702 

Los Angeles, California ·90013 

Contact phone (213) 269-6232 

contact ernan Matlhew.Heyn@doj.ca.gov 

Where should payments to the creditor oo sent? (if 

different) 

OFFICE OF EMERGENCY SERVICES 

Attn: Tabitha Stout, Acting Deputy 

Director - Finance and Administration 

3650 Schriever Avenue 

Mather, California 95655 

Contact phone (916) 845-8357 

contact emal Tabitha.Stout@calOES.ca.gov 

4 . Doos this claim amend O No 

one already filed? 6zl Yes. Claim number on court claims registry ~f known) 78463 & 79429 Filed on 10/21/2019 

5. Do you know if anyone 

else has flied a proof 

of claim for this claim? 

OfflCiel Farm 41 O 

liZi No 

• Yes. Who made the earlier filing? _ _ _ 

Proof of Clalm 

Mlol / DO I YYYY 

1111 111111111111 

193008880032146 

page 1 

Case: 19-30088 Doc# 5096-3 Filed: 12/12/19 Entered: 12/12/19 15:58:14 Page 2

of 10
l 

I 

Dive Information About the Claim as of the Dati,t the Case Was Flied 

6 . Do you have any nurnb&r !ill No 

you use to Identify the D Yes. Last 4 digits of the debtor's accou,I or any number you use to identify the debtor: _ _ debtor? -- ----

7. How much Is th& claim? $ 99,354,738.00 . Does this amount Include lnter&st or other charges? 

li!f No 

0 Yes. Attach statement Henning Interest, fees, expenses, or other 

charges required by Bankruptcy R(je 3001 (c)(2)(A). 

8. What Is the basis of the Examples: Goods sold, money loaned, lease, services performed, personal Injury or wrongful death, or credll card. 

claim? 

Attach redacted copies of WlY documents supporfug the dalm required~ Bankl\¥Xcy Rule 3001 (c). 

Umtt disclosing Information that Is enUtled to privacy, such as health care information. 

Disaster assistance provided in connection with the Butte Fire (see attached) 

9. Is all or part of tile clalm ~No 

secured? • Yes. The claim Is secured by a lien on property. 

Nature of property: 

D Real estate. If the claim Is secured by the debtor's pr1nclpat residence, file a Mortgage Proof of Claim 

Attachment (Official Form 41 0·A) with this Proof of Claim. 

D Motor vehicle 

D Other. Describe: 

Basis for perfection: 

Attach redacted copies ol documents, if any, that show evidence of perfection of a security interest (for 

example, a mortgage, lien, certificate of title, financing statement, or other document that shows the lien has 

been filed or recorded.) 

Value of property: $ 

Amount of the claim that is secured: $ 

Amount of the clalm that Is unsecured: $ (The sun of the secured and \.l"lseclnd 

amoun1s should match the amount In l ne 7 .) 

Amount necessary to cure any default as cl Iha date of the petition: $ 

Annual Interest Rato (when case was filed) ___ % 

• Fixed 

D Variable 

10. Is this claim based on a 5Zf No 

leas&? 

D Yes. Amount necessary to cure any default as of the date of the petition. $ 

11. Is this claim subject to a if No 

right of setoff? • Yes. Identify the property: 

Official Form 410 Proof of Claim page2 

Case: 19-30088 Doc# 5096-3 Filed: 12/12/19 Entered: 12/12/19 15:58:14 Page 3

of 10
12. ls all or part of the claim 

entitled to priority under 

11 U.S.C. § S07(a)? 

A Claim may be partly 

priority and partly 

nonpriorily. For example. 

in some categories, the 

law limits the amount 

entitled to priority. 

Sign Below 

The person completing 

this proof of claim must 

sign and date it. 

FRBP 9011(b). 

ltf No 

0 Yes. Check one: 

0 Domestic support obligations (including alimony and child support} under 

11 U .S.C. § 507{a)(1)(A) or (a)(1)(B). 

0 Up to $2,850' of deposits toward purchase. lease, or rental of property or services for 

personal. famijy_ or household use. 11 U.S.C. § 507(a)(7). 

Amount tmlltled to priority 

$ _______ _ 

$ _ ______ _ 

D Wages, salaries, or commissions (up to $12,850') earned within 180 days before 1he 

bankruptcy petition is filed or 1he debtor's business ends, whichever is earlier. $ ________ _ 

11 U.S.C. § 507(a)(4). 

0 Taxes or penalties owed to govemmental units. 11 U.S.C. § 507(al(8). $ ________ _ 

0 Contributions to an employee benefit plan. 11 U.S.C. § 507(a)(5}. $ ________ _ 

0 Other. Specify subsection of 11 U.S.C. § 507(a)LJ that applies. $ _ ______ _ 

• Amounts are subject to adjustment on <1/01/19 and every 3 year,; alter that (OC' ca••• begun on OC' after the date ol adjustment. 

Check the appropriate box: 

0 I am the creditor. 

ltf I am the creditor's attorney or aulhorlzed agent 

If you file this daim O I am the trustee, or the debtor, or their authorized agent. Bankruplcy Rule 3004. electronically, FRBP D 

5005{a)(2) aUthorizes courts I am a guarantor, surely, endorser. or other codebtor. Bankruptcy Rule 3005. 

lo establish local rules 

specifying whal a signature 

is. 

A person who files a 

fraudulent claim could be 

f ined up to $500,000, 

imprisoned for up to 5 

years, or both. 

18 U.S.C. §§ 152, 157, and 

3S71. 

Official Form 410 

I understand that an authorized signature on this Proof of Claim serves as an acknow1edgmenl that when calculaling the 

amount of the claim. the creditor gave the debtor credit for any paymenls received toward the debt. 

I have examined lhe 1nformat1on in I his Prooi of Claim and have a reasonable belief !hat the information is true 

and correct 

I declare under penally of perjury thal the foregoing 1s true and correct. 

Executed on date 11 /15/2019 MM I DD / YYYY 

~--- --

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

Name Tabitha Stout 

First name Middle name Last name 

T1He Acting Deputy Director - Finance and Administration 

Company California Governor's Office of Emergency Services 

Identify the corporate servicer as the company W the authorized agent is a servicer. 

Address 3650 Schriever Avenue 

Number Stleet 

Mather CA 95655 

City 

Contact pt,o,,e (916) 845-8357 

State 

Emu 

ZIP Code 

Tabitha.Stout@calOES.ca.gov 

Proof of Claim page 3 

Case: 19-30088 Doc# 5096-3 Filed: 12/12/19 Entered: 12/12/19 15:58:14 Page 4

of 10
Claim Number: 87754

, 

United States Bankruptcy Court, Northern District of California 

RECEIVED 

NOV 15 2019 

PRIME CLERK LLC 

FIii 1r1 this inlormat,on to 1<le11tify t 11e case (Select only one Dchtor per cla111 form). 

D PG&E Corporation (19-30088) 

0 Pacific Gas and Electric Company {19-30089) 

Official Form 41 0 

Proof of Claim 04/16 

Read the Instructions before fllllng out this fonn. This form Is for making a claim for paymeot In a bankruptcy caso. Do not use this form to 

make a requost for payment of an administrative expense. Make such a request according to 11 U.S.C. § 503. 

Fllors must leavo out or redact lnlonnation that is entitled to privacy on this form or on any attached doC\Jments. Attach redacted copies of any 

documents that support the claim, such as promissory notes, pt.n:hase orders, Invoices, Itemized statements of running accounts, conlracts, Judgments, 

mortgages, and security agreements. Do not send original documents; they may be destroyed after scanning. II the documents are not available, 

explain In an attachment. 

A person who tiles 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 tho lnfonnatlon about the clalm as of tho date the case was flied. That dato Is on the notlco of bankruptcy (Fonn 309) that you received. /2~ate Stamped Copy Returned 

Identify the Claim [ ] No Self-Addressed Stamped Envelope 

1. Who ls tho curront 

creditor? California Govenor's Office of Emergency Services 

Name or the cumint creditor (the pefSOn or entity to be paid !or thia dalm) 

0 0,er n•mo• the cred'lor used with the cleb1or c_..:a:.;.1...: 0:..:E::.S;:::_ _______ ____________ _ 

-- - ------- ---- ---- - --· -·-···- - 2. Has this claim boen 

acquired from 

someono olse? 

1

3. Whore should notlcos 

and paymonts to the 

croditor be sont? 

Federal Rule of 

Bankruptcy Procedure 

(FRBP) 2002(9) 

&1 No 

D Yes. From whom? ___ ______ ______ _____ _ 

Where should notices to the creditor be sent? 

CALIFORNIA DEPARTMENT OF JUSTICE 

OFFICE OF THE ATTORNEY GENERAL 

Matthew C. Heyn, Deputy Attorney General 

300 South Spring Street, Suite 1702 

Los Angeles, California 90013 

Contact phone (213) 269-6232 

contect omal Matthew.Heyn@doj.ca.gov 

Whero should payments to tho creditor be s.ent? (1 I 

different) 

OFFICE OF EMERGENCY SERVICES 

Attn: Tabitha Stout, Acting Deputy 

Director•· Finance and Administration 

3650 Schriever Avenue 

Mather, California 95655 

Con:ad phone (916) 845-8357 

contact email Tabitha.Stout@calOES.ca.gov 

---- ------ - ------- - - - - - - ----

4. Does this claim amend 

one alniady filed? 

5. Oo you know If anyone 

else has flied a proof 

of clalm for this claim? 

Official Form 410 

0 No 

~ Yes. Claim number on court claims registry (If known) 77624 & 78495 FUed on 10/21/2019 MM / DD / VYYY 

(i1 No 

D Yes. Who made tho eartier filing? 

Proof of Claim 111111 Ulllllllll llll 

193008880032147 

page 1 

Case: 19-30088 Doc# 5096-3 Filed: 12/12/19 Entered: 12/12/19 15:58:14 Page 5

of 10
•:.., -~ Give Information About the Clalm as of the Date the Case Was FIie~ 

6. Do you have any (IUmber li1 No 

you use to Identify the D Yes. Last 4 digits of the debtor's account or any number you use lo Identify the debtor: _ _ debtor? - - ----

7. How much Is the clalm? 5 281 ,230,590.00 . Does this amount Include Interest or other charges? 

@ No 

0 Yes. Attach statement Itemizing Interest, fees, expenses, or other 

charges required by Bankruptcy Rute 3001 (c)(2)(A). 

8, What Is the basis of the Examples: Goods sold, money loaned. lease, services performed, personal injury or wrongful death, or cred t card. 

clalm? 

Attach redacted copies of any documents supporting the claim required by Bankruptcy Rule 3001 (c). 

Limit disclosing lnformallon that is entitled to privacy, such as health care Information. 

Public assistance necessitated by the North Bay Fires (Disaster Declaration No. DR-4344) 

9. Is all or part of the cl aim li1 No 

secured? D Yes, The claim Is secured by a lien on property. 

Naturo of property: 

0 Real estate. If the claim is secured by the debtor's pl'lnclpal re! ldence, file a Mortgage Proof of Claim 

Attachment (Official Form 41 0-A) with this Proof of Claim. 

0 Motor vehicle 

D Other. Describe: 

Basis for perfection: - ----- Altach redacted copies of documenls, If any, lnat sriow ev dence of perfection of a secun:y ntercst (for 

example, a mortgage, lien certificate of atle, fir.anctng statemen:. or other docu-nent that shows the lion ~as 

been fllad or recorded.) 

Value of property: s 

Amount of the clalm that Is socurod: $ 

Amount of the claim that Is unsecured: $ (The sum of the secured and unsecured 

amounts should match the amount In ine 7 .) 

Amount necessary to curo any default as of the date of tho petition: $ 

Annual Interest Raio (when case was filed) ___ % 

D Fixed 

0 Var1able 

10. Is this clalm based on a fiZl No 

leaso? 

D Yes. Amount necessary to cure any default as of the date of the petition. $ 

11. Is this claim subject to a fiZl No right of setoff? 

D Yes. Identify the property: 

·-

Official Form 41 0 Proof of Claim page 2 

Case: 19-30088 Doc# 5096-3 Filed: 12/12/19 Entered: 12/12/19 15:58:14 Page 6

of 10
12. Is all or part of the claim 

entitled to priority under 

11 U.S.C. § 507(a)7 

A claim may be partly 

priority and partly 

nonpriority. For example. 

in some categories, the 

law limits the amount 

entitled to priority. 

Sign Below 

The person completing 

this proof of claim must 

sign and date it 

FRBP 9011(b). 

~ No 

D Yes. Check one: 

D Domestic suppon obligations (including alimony and child suppon) under 

11 U.S.C. § 507(a)(1)(A) or (a)(1){8). 

D Up to $2,850° of deposits toward purchase, lease, or rental of property or services for 

personal. family, or household use. 11 U.S.C. § 507(a)(7). 

D Wages, salaries, or commissions (up to $12,850°) earned within 180 days before the 

Amount &ntitl~ to priority 

s _______ _ 

$ ________ _ 

bankruptcy petition is filed Of the debtor's business ends, whichever is earlier. $ ________ _ 

11 U.S.C. § 507(a)(4). 

D Taxes or penalties owed to governmental units. 11 U .S.C. § 507(a)(8). $ _______ _ 

D Contributions to an employee benefit plan. 11 U.S.C. § 507(a)(5). s _______ _ 

D Other. Specify subsection of 11 U.S.C. § 507(a)LJ that applies. S _______ _ 

• Amounts are subject to acjjuslment on 4/01/19 and every 3 years aflerthat for cases begun on or after the date of adjllStmenl 

Check the appropriate box: 

D I am the Cfeditor. 

!if I am the Cfeditor's attorney or authorized agent. 

If you file this claim D I am the trustee, or the debtor, or their authorized agent. Bankruptcy Rule 3004. 

electronically, FRBP • 

5005(a)(2) authorizes courts I am a guarantor, surety, endorser, or other codebtor. Bankruptcy Rule 3005. 

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, o r both. 

18 U.S.C. §§ 152,157, and 

3571. 

Official Form 410 

I understand that an authorized signature on this Proof of Claim serves as an acknowledgment thal 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 behef that the 1nfonnat1on 1s true 

and correct. 

I declare under penalty of perjury that the foregoing is true and correct. 

Executed on date 11/15/2019 

MM I 00 I YYYY 

(~ 

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

Name Tabitha 

FirstnJlme Middle name 

Stout 

Last nama 

Acting Deputy Director - Finance and Administration 

Company California Governor's Office of Emergency Services 

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

Address 3650 Schriever Avenue 

Number Street 

Mather CA 95655 

State ZIP Code 

Contact phone (916) 845-8357 Emai Tabitha.Stout@calOES.ca.gov 

----·----- - --- - - - ------~ 

Proof of Claim pageJ 

Case: 19-30088 Doc# 5096-3 Filed: 12/12/19 Entered: 12/12/19 15:58:14 Page 7

of 10
Claim Number: 87755

United States Bankruptcy Court, Northern District of California 

Fill 111 this 1nforrn;ttio11 to 1de11hfy the case (Select only ore Debtor p~t claim form): 

D PG&E Corporation (19-30088) 

12) Pacific Gas and Electric Company (19-30089) 

Official Form 410 

~roof of Claim 

RECEIVED 

NOV 15 2019 

PRIME CLERK LLC 

04116 

Read the Instructions before fllllng out this form. This form Is for making a claim for payment in a bankruptcy case. Do not use this form to 

make a request for payment of an 11dmlnlstratlvo expense. Make such a request according to 11 U.S.C. § 503. 

Fliers must leave out or redact infonnalion tl1at Is entllled to privacy on this form or on any atlached docunents. Attach redacted copies of any 

documents that support the claim, such as promissory notes. plrchase orders, Invoices, Itemized statements of running accounts, contracts, judgments, 

mortgages, and security agreements. Do not send original documents; they may be destroyed after scanning. If the documents are not available, 

explain In an attachment. 

A person who flies a frauwlenl claim could be Hned up to $500,000, imprisoned for up to 5 years, or both. 1 B U.S.C. §§ 152, 157, and 3571. 

,. FIU in all the information about the claim as of the date tho case was flied. That date Is on the notice of bankruptcy (Form 309) that you received . 

. .,:-

Identify the Claim 

' Date Stamped Copy Returned 

/r 1 No Self-Addressed Stamped Envelope 

1 . Who ls tho current 

crodltor? 

[ opy r 

California Govenor's Office of Emer:,;gz,::e:c:nc=: cLcy'7S:.::: e7'rv;.;.ic=,:e::,::s:..,...-_______________ _ Name of the current cteditoo-(the person or entity to be paid. for this claim) 

Other names the cred~or uoed with the debtor C:.::a:.:.. l ..=O:.:::E:..:S::.._ _ __________________ _ 

t--- -------------------------------- ----- - ------ -----l 

2 . Has this claim been 

acquired from 

someone else? 

0 No 

0 Yes. From whom? __________________________ _ 

----·----.. -····----.. -----··--------- ·----·- ------•··- ·-·-------------------- 3. Where should notices 

and payments to the 

creditor be sent? 

4. 

5. 

Federal Rule of 

Bankruptcy Procedlre 

(FRBP) 2002(g) 

Does this claim amend 

one already flied? 

Do you know If anyone 

olso has filed a proof 

of claim for this claim? 

Official Form 410 

WhO'ro should notices to the creditor be sent? 

CALIFORNIA DEPARTMENT OF JUSTICE 

OFFICE OF THE ATTORNEY GENERAL 

Matthew C. Heyn, Deputy Attorney General 

300 South Spring Street, Suite 1702 

Los Angeles, California 90013 

Contact phOne _(2_1_3_)_2_6_9_-6_2_3_2 __ _ 

Contactemai Matthew.Heyn@doj.ca.gov 

0 No 

Where should payments to the creditor be sent? (If 

different) 

OFFICE OF EMERGENCY SERVICES 

Attn: Tabitha Stout, Acting Deputy 

Direct.or•· Finance and Administration 

3650 Schriever Avenue 

Mather, California 95655 

Contact phono '-(9_1_6..c.}_845-8_ _3_5_7 __ _ 

Cootact omai Tabi1ha.Stout@calOES.ca.gov 

Iii' Yes. Claim number on court claims registry (if known) 79398 Filed on 10/21/2019 

MM I DO / yyyy 

··------

~ No 

D Yes. \Mio made the earlier filing? 

Proof of Claim 1>39e 1 

Case: 19-30088 Doc# 5096-3 Filed: 12/12/19 Entered: 12/12/19 15:58:14 Page 8

of 10
Give Information About the Claim as of the Date the Case Was Flied 

6. Do you havo any number ~No 

you uso to ldenury the D Yes. Last 4 digits of the debtor's account or any number you use to Identify the debtor: _ _ debtor? - - ----

7. How much Is tho claim? $ 2,313,479,642.00 . Does this amount Include Interest or other charges? 

!¥1' No 

D Yes. Attach statement ltemlzJng Interest, fees, expenses, or other 

charges required by Bankruptcy Rule 3001(c)(2)(A). 

8. What Is the basis of the Examples: Goods sold, money loaned, lease, services performed, personal injury or wrongful death, or credlt card. 

claim? 

Al18Ch redacted copies of any documents supporting the claim requre<I by Bankruptcy Rule 3001(c). 

Limit disclosing infonnallon tha1 Is entitled to privacy, suc:11 as health care information. 

Public assistance necessitated by the Camp Fire (Disaster Declaration No. DR-4407) 

9. Is all or part of the claim liZi No 

secured? • Yes. The claim Is secured by a Ren on property. 

Nature of property; 

D Real estate. If the claim is secured by the debtor's principal residence, file a Mortgago Proof of Claim 

Attachment (Official Form 410-A) with this Proof of Claim. 

D Motor vehicle 

D Other. Describe: 

Basis for perfoctlon: 

Attach redacted copies of doc,rncnts. If any, that show evidence of perfection of a security Interest (for 

example, a m01t9age, hen, certlttca te of title, financing statement, or other document that shows too lien has 

been filed or recorded ) 

Value of property: s 

Amount of the claim that Is secured: $ 

Amount of tho claim that Is unsecured: $ (The sum of the secured and unsecured 

amounts should match the amount lo line 7.) 

Amount necessary to cure any default as of the date of the petition: $ 

Annual lnterost Rate (when caso was flied) ___ % 

D Fixed 

D Variable 

10. Is this claim based on a fiZi No 

loaso? 

• Yes. Amount necessary to curo any default as of the data of ttae potltlon. $ 

11. Is this clalm subject to a fiZi No 

right of setoff? 

D Yes. tdenUfy lhe properly: 

Official Form 410 Proof of Cl aim page 2 

Case: 19-30088 Doc# 5096-3 Filed: 12/12/19 Entered: 12/12/19 15:58:14 Page 9

of 10
12. Is all or part of the claim 

entitled to priority under 

11 U.S.C. § 507(a)7 

A claim may be partly 

priority and partly 

nonpriority. For example, 

In some categories, the 

law limits the amount 

entitled to priority. 

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 

f ined up to $500,000, 

Imprisoned for up to 5 

years, o r both. 

18 U.S.C. §§ 152, 157, and 

3571. 

Official Form 410 

li1' No 

0 Yes. Check one: 

0 Domestic support obligations (including alimony and child support) under 

11 U.S.C. § 507(a)(1)(A) or (a)(1)(B). 

0 Up lo s2.aso• of deposits toward purchase, lease, or rental of property or services for 

personal, family, or household use. 11 U.S.C. § 507(a)(7). 

Amount entltled to priority 

$. _______ _ 

$. ______ _ 

0 Wages, salaries. or commissions (up to s12.aso•1 earned within 180 days before the 

bankruptcy petition is filed or the debtor's business ends, whichever is earlier. $. ________ _ 

11 U.S.C . § 507(a)(4). 

0 Taxes or penalties owed to governmental units. 11 U.S.C. § 507(a)(8). $. _ ______ _ 

0 Contributions to an employee benefit plan. 11 U.S.C. § 507(a)(5). $. _______ _ 

0 Other. Specify subsection of 11 U.S.C. § 507(a)L) that applies. $ ______ _ _ 

• Amounts are subject to adjustment on 4/01/19 and every 3 years after that for casi,s begun on or after the date of adjustment 

Check the appropriate box: 

0 I am the creditor. 

llf I am the creditor's attorney or authorized agent. 

0 I am the trustee, or the debtor, or their authorized agent. Bankruptcy Rule 3004. 

0 I am a guarantor, surely, endorser. or other codebtor. Bankruptcy Rule 3005. 

I understand that an authorized signature on this Proof of Claim serves as an ac~nowtedgmcnt 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 belier U1at the information 1s true 

and correct. 

I declare under penally of perjury that the foregoing is true and correct. 

Executed on dale 11/15/2019 

MM I 00 I YYYY 

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

Name Tabitha Stout 

F11st name Middle name Last name 

Title Acting Deputy Director - Finance and Administration 

Company California Governor's Office of Emergency Services 

ldentrfy lhe corporate servicer as the company~ the authorized agent is a se,v,cer. 

Address 3650 Schriever Avenue 

Number Slreet 

Mather CA 95655 

City State ZIP Code 

Contact phone (916) 845-8357 Emai T abilha.Stout@calOES.ca.gov 

Proof of Claim page 3 

Case: 19-30088 Doc# 5096-3 Filed: 12/12/19 Entered: 12/12/19 15:58:14 Page 10

of 10