You are on page 1of 4

B 210A (Form 210A) (12/09)

UNITED STATES BANKRUPTCY COURT



District of Delaware


In re Perkins & Marie Callenders Inc. Case No. 11-11795

TRANSFER OF CLAIM OTHER THAN FOR SECURITY

A CLAIM HAS BEEN FILED IN THIS CASE or deemed filed under 11 U.S.C. 1111(a).
Transferee hereby gives evidence and notice pursuant to Rule 3001(e)(1) or (2), Fed. R. Bankr.
P., of the transfer, other than for security, of the claim referenced in this evidence and notice.



Debt Acquisition Group, LLC Gembecki Mechanical Services
Name of Transferee Name of Transferor


Name and Address where notices to transferee Court Claim # (if known): 592
should be sent: Amount of Claim: $1,743.75
10 Rockefeller Center, Suite 601 Date Claim Filed: 7/27/11
New York, NY 10020

Phone: 212 265 7016 Phone: 70407 695 6646
Last Four Digits of Acct #: ______________ Last Four Digits of Acct. #: __________

Name and Address where transferee payments
should be sent (if different from above):



Phone: ______________________
Last Four Digits of Acct #: ______________


I declare under penalty of perjury that the information provided in this notice is true and correct
to the best of my knowledge and belief.


By: /s/ Craig Ari Loren, Member Date: 8/2/2011
Transferee/Transferees Agent


Penalty for making a false statement: Fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. 152 & 3571.
B 10 (OIIicial Form 10) (04/10)

UNITED STATES BANKRUPTCY COURT __________ DISTRICT OF __________


PROOF OF CLAIM

Name oI Debtor: Case Number:

NOTE: This form should not be used to make a claim for an administrative expense arising after the commencement of the case. A request for payment of an
administrative expense may be filed pursuant to 11 U.S.C. 503.
Name oI Creditor (the person or other entity to whom the debtor owes money or property):

Check this box to indicate that this
claim amends a previously Iiled
claim.

Court Claim Number:
(If known)


Filed on:

Name and address where notices should be sent:




Telephone number:
Name and address where payment should be sent (iI diIIerent Irom above):




Telephone number:
Check this box iI you are aware that
anyone else has Iiled a prooI oI claim
relating to your claim. Attach copy oI
statement giving particulars.

Check this box iI you are the debtor
or trustee in this case.
1. Amount of Claim as of Date Case Filed: $

II all or part oI your claim is secured. complete item 4 below; however. iI all oI your claim is unsecured. do not complete
item 4.

II all or part oI your claim is entitled to priority. complete item 5.

Check this box iI claim includes interest or other charges in addition to the principal amount oI claim. Attach itemized
statement oI interest or charges.

5. Amount of Claim Entitled to
Priority under 11 U.S.C. 507(a). If
any portion of your claim falls in
one of the following categories,
check the box and state the
amount.

SpeciIy the priority oI the claim.

Domestic support obligations under
11 U.S.C. 507(a)(1)(A) or (a)(1)(B).

Wages. salaries. or commissions (up
to $11.725*) earned within 180 days
beIore Iiling oI the bankruptcy
petition or cessation oI the debtor`s
business. whichever is earlier 11
U.S.C. 507 (a)(4).

Contributions to an employee beneIit
plan 11 U.S.C. 507 (a)(5).

Up to $2.600* oI deposits toward
purchase. lease. or rental oI property
or services Ior personal. Iamily. or
household use 11 U.S.C. 507
(a)(7).

Taxes or penalties owed to
governmental units 11 U.S.C. 507
(a)(8).

Other SpeciIy applicable paragraph
oI 11 U.S.C. 507 (a)().

Amount entitled to priority:

$

*Amounts are subject to adjustment on
4/1/13 and every 3 years thereafter with
respect to cases commenced on or after
the date of adjustment.
2. Basis for Claim: _____________________________
(See instruction #2 on reverse side.)
3. Last four digits of any number by which creditor identifies debtor: ______

3a. Debtor may have scheduled account as: ____________________
(See instruction #3a on reverse side.)
4. Secured Claim (See instruction #4 on reverse side.)
Check the appropriate box iI your claim is secured by a lien on property or a right oI setoII and provide the requested
inIormation.

Nature of property or right of setoff: Real Estate Motor Vehicle Other
Describe:

Value of Property:$________________ Annual Interest Rate_________%

Amount of arrearage and other charges as of time case filed included in secured claim,

if any: $__________________ Basis for perfection: ____________________

Amount of Secured Claim: $__________________ Amount Unsecured: $__________________

6. Credits: The amount oI all payments on this claim has been credited Ior the purpose oI making this prooI oI claim.

7. Documents: Attach redacted copies oI any documents that support the claim. such as promissory notes. purchase
orders. invoices. itemized statements oI running accounts. contracts. iudgments. mortgages. and security agreements.
You may also attach a summary. Attach redacted copies oI documents providing evidence oI perIection oI
a security interest. You may also attach a summary. (See instruction 7 and definition of redacted on reverse side.)

DO NOT SEND ORIGINAL DOCUMENTS. ATTACHED DOCUMENTS MAY BE DESTROYED AFTER
SCANNING.

II the documents are not available. please explain:

D Signature: The person Iiling this claim must sign it. Sign and print name and title. iI any. oI the creditor or
other person authorized to Iile this claim and state address and telephone number iI diIIerent Irom the notice
address above. Attach copy oI power oI attorney. iI any.



FOR COURT USE ONLY
Penalty for presenting fraudulent claim: Fine oI up to $500.000 or imprisonment Ior up to 5 years. or both. 18 U.S.C. 152 and 3571.



Date:
District of Delaware
Perkins & Marie Callender's Inc. 11-11795
Gembecki Mechanical Services
!
1311 Seminola Blvd.!
Casselberry, FL 32707
407 695 6646
1743.75
Services Performed
7/21/11

You might also like