United States Bankruptcy Court, Southern District of Ohio (Western Division) MMLID: 8600143 Fill in this information to identify the case (Select only one Debtor per claim form): Debtor: C4 Case Number: [ff f?ggj-u? FEB 1 2023 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 (other than a claim entitled to priority under 11 U.S.C. 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 ?ned 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. Identify the Claim 1 Date Stamped Copy Returrle 1.. 3 :1'8 Stamped Enve ope I I 0 Co Provided 2:23:33? Name of the current creditor (the person or entity to be paid for this claim) Other names the creditor used with the debtor 32. Has this claim been 9 No acquired from E3. Where should notices Where should notices to the creditor be sent? Where should payments to the creditor be sent? (it - and payments to the different) be 59"? OHIO COAL Federal Rule of 17 SOUTH HIGH STREET SUITE 215 Bankruptcy Procedure COLUMBUS OH 43215 (FRBP) 2002(9) - 4641? (2 Contact phone Contact phone Contact email fig?? {rd/ Contactemail 6) if" 1t (J (?pt 1?25 4 54/. 4, Does this claim amend KNO 5 Do you know if anyone m0 7 one already f'led' CI Yes. Claim number on court claims registry (ifknown) Filed 00 MM i? DD i . else has filed a proof Yes. Who made the earlier?iing? of claim for this claim? 19568858000054? Claim Number: 1191 Proof of Claim page 1 Give Information About the Claim as of the Date the Case Was. Filed .6. Do you have any number i you use to identify the CI Yes. Last 4 digits of the debtor?s account or any number you use to identify the debtor: debtor? . 7 How much is the claim? 5 5r? . Does this amount include interest or other charges? 3 El Yes. Attach statement itemizing interest, fees, expenses, or other charges required by Bankruptcy Rule 3001(c)(2)(A). What is the basis of the Examples: Goods sold, money loaned, lease, services performed, personal injury or wrongful death, or creditcard. claim? Attach redacted copies of any documents supporting the claim required by Bankruptcy Rule 3001 Limit disclosing information that is entitled to privacy, such as health careinformationpart of the claim ?No secured? El Yes. The claim is secured by a lien on property. Nature of property: Cl Real estate. If the claim is secured by the debtor's principal residence, file a Mortgage Proof ofCiarm Attachment (Official Form 410-A) with this Proof of Claim. El Motor vehicle El 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 ?led 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) El Fixed El Variable ;10. Is this claim based on a m0 lease? Yes. Amount necessary to cure any default as of the date of the petition. E11. Is this claim subject to a GZNE) right of setoff? Cl Yes. Identify the property: Modi?ed Of?cial Form 410 Proof of Claim page 2 12. Is all or part of the claim entitled to priority under 11 U.S.C. 507(a)? A claim may be partly priority and partly nonpriority. For example, in some categories, the law limits the amount entitled to priority. 13. is all or part of the claim entitled to administrative priority pursuant to 11 U.S.C. 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. Modified Official Form 410 are Yes. Check one: Amount entitled to priority CI Domestic support obligations (including alimony and child support) under 11 U.S.C. 507(a)(1)(A) or Up to $3,025* of deposits toward purchase, lease, or rental of property or services for personal, family. or household use. 11 use. 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. '5 11 U.S.C. 507(a)(4). Taxes or penalties owed to governmental units. 11 U.S.C. 507(a)(8). 3 El Contributions to an employee bene?t plan. 11 use. 507(a)(5). CI Other. Speciw subsection of 11 U.S.C. thatapplies. Amounts are subject to adjustment on 4101f22 and every 3 years after that for cases begun on or after the date of adjustment. ea?- Yes. Indicate the amount of your claim arising from the value of any goods received ?35 by the Debtor within 20 days before the date of commencement of the above case. in which the goods have been sold to the Debtor in the ordinary course of such Debtor's business. Attach documentation supporting such claim. Check the appropriate box: CI I am the creditor. I am the creditor's attorney or authorized agent. CI 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 calculatingthe 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 beliefthat the information is true and correct. I declare under penalty of perjury thatj the foregoing is true and correct. Executed on date lgnatu Print the name of the person who Is completing and signing this claim: Name fair/(z Err/f (la/9G First name Middle name Last nan?ha Title 5' Company Identify the corporate servicer as the company if the authorized agent is a servicer. Address 7 f?v't?fd 57? Number Street 6% 8D 262/ City State ZIP Code fl . Contact phone ?/fa 5?159h @115? Email ?If :7 7 66/1 ?9 2?er Proof of Claim page 3 a. 034691223141850 FOREVER THE POWER 17 South High Street, Suite 310 Columbus, Ohio 43215 . - 17/53! 6523 9% 54/2 My