Case 3:19-bk-30290 Claim 2-1 Filed 07/24/19 Desc Main Document Page 1 of 4 Fill in this information to identify the case: Debtor 1 BLACKJEWEL HOLDINGS, L.L.C. Debtor 2 (Spouse, if filing) United States Bankruptcy Court for the: SOUTHERN District of WEST VIRGINIA (State) Case number 3:19-BK-30290 Official Form 410 Proof of Claim 04/19 Read the instructions before filling 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 administrative expense. Make such a request according to 11 U.S.C. § 503. 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, such as promissory notes, purchase 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 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 the date the case was filed. That date is on the notice of bankruptcy (Form 309) that you received. Part 1: Identify the Claim 1. Who is the current creditor? Department of the Treasury - Internal Revenue Service 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? 3. Where should notices and payments to the creditor be sent? Federal Rule of Bankruptcy Procedure (FRBP) 2002(g) No Yes. From whom? Where should notices to the creditor be sent? Where should payments to the creditor be sent? (if different) Internal Revenue Service Name Internal Revenue Service Name P.O. Box 7346 Number 400 N 8th Street, Box 76 M/S ROOM 898 Street Philadelphia City Contact phone PA State Number 19101-7346 ZIP Code 1-800-973-0424 Contact email Street Contact phone 23219 ZIP Code VA State Richmond City (804) 916-8064 Contact email Creditor Number: 2677268 Uniform claim identifier for electronic payments in chapter 13 (if you use one) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 4. Does this claim amend one already filed? No Yes. Claim number on court claims registry (if known) Filed on: MM / DD 5. Do you know if anyone else has filed a proof of claim for this claim? Claim Number: 93 No Yes. Who made the earlier filing? / YYYY Case 3:19-bk-30290 Part 2: Claim 2-1 Filed 07/24/19 Desc Main Document Page 2 of 4 Give Information About the Claim as of the Date the Case Was Filed 6. Do you have any number you use to identify the debtor? 7. How much is the claim? No Yes. Last 4 digits of the debtor's account or any number you use to identify the debtor: $ 100.00 See Attachment Does this amount include interest or other charges? No Yes. Attach statement itemizing interest, fees, expenses, or other charges required by Bankruptcy Rule 3001(c)(2)(A). 8. What is the basis of the claim? Examples: Goods sold, money loaned, lease, services performed, personal injury or wrongful death, or credit card. Attach redacted copies of any documents supporting the claim required by Bankruptcy Rule 3001(c). Limit disclosing information that is entitled to privacy, such as health care information. Taxes 9. Is all or part of the claim secured? No Yes. The claim is secured by a lien on property. Nature of property: Real Estate. If the claim is secured by the debtor's principal residence, file a Mortgage Proof of Claim Attachment (Official Form 410-A) with this Proof of Claim. Motor Vehicle Other. Describe: Basis for perfection: Attach redacted copies of 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 claim that is unsecured: $ (The sum of the secured and unsecured amounts should match the amount in line 7.) Amount necessary to cure any default as of the date of the petition: Annual Interest Rate (when case was filed) $ % Fixed Variable 10. Is this claim based on a lease? 11. Is this claim subject to a right of setoff? No Yes. Amount necessary to cure any default as of the date of the petition. No Yes. Identify the property See Attachment $ Case 3:19-bk-30290 12. Is all or part of the claim entitled to priority under 11 U.S.C. §507(a)? Claim 2-1 Filed 07/24/19 Desc Main Document Page 3 of 4 No Yes. Check all that apply: Amount entitled to priority Domestic support obligations (including alimony and child support) under 11 U.S.C. § 507(a)(1)(A) or (a)(1)(B). A claim may be partly priority and partly nonpriority. For example, in some categories, the law limits the amount entitled to priority. $ Up to $3,025* of deposits toward purchase, lease, or rental of property or services for personal, family, or household use. 11 U.S.C. § 507(a)(7). $ Wages, salaries, or commissions (up to $13,650*) 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). $ Taxes or penalties owed to governmental units. 11 U.S.C. § 507(a)(8). $ Contributions to an employee benefit plan. 11 U.S.C. § 507(a)(5). $ Other. Specify subsection of 11 U.S.C. § 507(a)(__) that applies. $ *Amounts are subject to adjustment on 4/01/22 and every 3 years after that for cases begun on or after the date of adjustment. Part 3: Sign Below The person completing this Check the appropriate box: proof of claim must sign I am the creditor. and date it. FRBP 9011(b). I am the creditor's attorney or authorized agent. 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. 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 07/23/2019 MM / DD / YYYY /s/ L LORELLO (Signature) Print the name of the person who is completing and signing this claim: Name LORELLO L First name Middle name Title Bankruptcy Specialist Company Internal Revenue Service Last name Identify the corporate servicer as the company if the authorized agent is a servicer. Address 400 N 8th Street, Box 76 M/S ROOM 898 Number Street Richmond VA 23219 City State ZIP Code Contact Phone (804) 916-8064 Email: Case 3:19-bk-30290 Claim 2-1 Filed 07/24/19 Desc Main Document Proof of Claim for Internal Revenue Taxes Page 4 of 4 Form 410 Attachment Department of the Treasury/Internal Revenue Service In the Matter of: BLACKJEWEL HOLDINGS, L.L.C. 1051 MAIN STREET MILTON, WV 25541 Case Number 3:19-BK-30290 Type of Bankruptcy Case CHAPTER 11 Date of Petition 07/01/2019 The United States has not identified a right of setoff or counterclaim. However, this determination is based on available data and is not intended to waive any right to setoff against this claim debts owed to this debtor by this or any other federal agency. All rights of setoff are preserved and will be asserted to the extent lawful. Unsecured General Claims Taxpayer ID Number Kind of Tax Tax Period XX-XXX4745 PTRSHP 12/31/2018 1 Date Tax Assessed Tax Due Estimated- SEE NOTE $100.00 Total Amount of Unsecured General Claims: 1 LIABILITY IS ESTIMATED BASED ON AVAILABLE INFORMATION BECAUSE THE RETURN HAS NOT BEEN FILED. THIS CLAIM MAY BE AMENDED AS NECESSARY AFTER THE DEBTOR FILES THE RETURN OR PROVIDES OTHER REQUIRED INFORMATION. Page 1 of 1 Interest to Petition Date $0.00 $100.00