Case 09-34022 Claim 1920-1 Filed 04/05/10 Desc Main Document Page 1 of 2

B 10 (Official Form 10) (12/08)

UNITED STATES BANKRUPTCY COURT PROOF OF CLAIM

Name of Debtor Case Number;

BURR OAK HOLLDINGS OF ILLINOIS, LLC 09-34022
NOTE: This fon,z should not be used to ma/ce a c/alp, for an adazinistrative expense arising after the commencement ofthe case. A requestfor payment ofan
ad,ninistrative expense may be filed pursuant to ii USC. .f 503.
Name of Creditor (the person or other entity to whom the debtor owes money or property): C Check this box to indicate that this
KAREN STURGES mece of deceased Tyrea Bailey (DOD 8//I 989). claim amends a previously filed
Name and address where notices should be sent: claim.
CHARLIP LAW GROUP, LC
1930 Harrison Street, Court Claim Naniber,_____________
(If/mown)
Suite 208, Hollywood, FL 33020
Telephone number:
(954) 92l-2l3t Filed on:_______________________

Name and address where payment shoutd be sent (if different from above): C Check this box if you are aware that
CHARLIP LAW GROUP, LC anyone else has filed a proof of claim
1930 Harrison Sireet, relating to your claim. Attach copy of
statement giving particulars.
Suite 208, Hollywood, FL 33020
Telephone number: C Check this box if you are the debtor
(954) 921-2131 or trustee in this case.
I. Amount of Claim as of Date Case Filed, S ~ Oj ~D 0 5. Amount of Claim Entitled to
Priority under 11 U.S.C. §507(a). If
If all or part of your claim is secured, complete item 4 below; however, if all of your claim is unsecured, do not complete any portion of your claim falls in
item 4. one of the following categories,
check the box and state the
if alt or part of your claim is entitled to priority, complete item 5. amount.

U Check this box if claim includes interest or other charges in addition to the principal amount of claim. Attach itemized Specify the priority of the claim.
statement of interest or charges.
U Domestic support obligations under
2. Basis for Claim, PERSONAL INJURY ii U.S.C. §507(a)(1)(A) or (a)(iXB).
(See instruction #2 on reverse side.)
3. Last foui~ digits of any number by which creditor identifies debtor: N/A C Wages, salaries, or commissions (up
to $10,950*) earned within 180 days
3a. Debtor may have scheduled acconat as: N/A before filing of the bankruptcy
(See instniction #3a on reverse side.) petition or cessation of the debtor’s
4. Secured Claim (See instniction #4 on reverse side.) business, whichever is earlier—il
Check the appropriate box if your claim is secured by a lien on property or a right of setoff and provide the requested U.S.C. §507 (aX4).
information.
C Contributions to an employee benefit
Nature of property or right of setolT: C Real Estate C Motor Vehicle C Other plan—il U.S.C. §507 (a)(5).
Describe:
C Up to 52,425* of deposits toward
VaILTO of Property:S__0.00 Annual Interest Rate_% purchase, lease, or rental of property
or services for personal, family, or
Amount of arrearage and other charges as of time case filed included in secured claim, household use—il U.S.C. §507
(a)~7).
if any: $ 0.00 Basis for perfection: N/A
C Taxes or penalties owed to
Amount of Secured Claim, $ 0.00 Amount Unsecured: $ 0.00 govemmentalunits —11 U.S.C. §507
(a)(8).
6. Credits, The amount of all payments on this claim has been credited for the purpose ofmaking this proof of claim.
C Other — Specify applicable paragraph
7. Documents, Atlach redacted copies of any documents that support the claim, such as promissory notes, purchase of 11 U.S.C. §507 (aX_i.
orders, invoices, itemized statements of running accounts, contracts, judgments, mortgages, and security agreements.
You may aho attach a summary. Attach redacted copies of documents providing evidence of perfection of Amount entitled to priority,
a security interest. You may also attach a summary. (See instruction 7 and definition of ‘redacted” on reverse side) $________________

DO NOT SEND ORIGINAl. DOCUMENTS. AVrACFIED DOCUMENTS MAY BE DESTROYED AFTER

SCANNING. Amounts are subject to adjustment on
4/1/10 and every 3 years thereafter with
If the documents are not available, please explain: SEE ATTACHED respect to cases commenced on or after
the date ofadjustment.
~ FORCOURTUSE ONLY
~ Date: 3/ 4 Signature: Theperson filing this claim mustsign it. Sign and printname andtitle, if any, of the creditoror
.5 I3~ other person authorized to file this claim and slate address and telephone number if different from the notice
addre
~ Attach of attorney, if any. It p-te”~ J. Sn’tz4 dt
/fs-2/ 5. tsilct-’ca4
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Penalty~sentingfraudulet~/aim: Fiä~ of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §~ 152 and 3571.
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Case 09-34022
CoUntflfCcv4c Claim 1920-1 FiledDAVID
04/05/10 Desc Main
ORR~CØuhty ClerkDocument AUG l4:zto~~t
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