Free form 24 - New Jersey

D.N.J. Local Form 24

U NITED S TATES B ANKRUPTCY C OURT D ISTRICT OF N EW J ERSEY
In re Chapter 11 Case Number NOTE: This form should not be used for an unsecured claim arising prior to the commencement of the case. In such cases, a proof of claim should be filed in accordance with Official Form 10. Name of Creditor (The person or other entity to whom the debtor owed money or property.) _________________________________________ Name and Addresses Where Notices Should Be Sent:

REQUEST FOR PAYMENT OF ADMINISTRATIVE EXPENSE

ACCOUNT OR OTHER NUMBER BY WHICH CREDITOR IDENTIFIES DEBTOR: 1. BASIS FOR CLAIM Goods Sold Services performed Money loaned Personal injury/wrongful death Taxes Other (Describe briefly) 2. DATE DEBT WAS INCURRED: 3. TOTAL AMOUNT OF REQUEST AS OF ABOVE DATE: _________________

Check box if you are aware that anyone else has filed a proof of claim relating to your claim. Attach copy of statement giving particulars. Check box if you have never received any notices from the bankruptcy court in this case. Check box if the address differs from the address on the envelope sent to you by the THIS SPACE IS FOR COURT USE ONLY court. Check here if this request: replaces a previously filed request, dated: amends a previously filed request, dated: Retiree benefits as defined in 11 U.S.C. §1114(a) Wages, salaries and compensations (Fill out below) Provide last four digits of your social security number

Check this box if the request includes interest or other charges in addition to the principal amount of the request. Attach itemized statement of all interest or additional charges. 4. Secured Claim Check this box if your claim is secured by collateral (including a right of setoff). Brief Description of Collateral: Real Estate Motor Vehicle Other (Describe briefly)___________________________ Value of Collateral: $ Check this box if there is no collateral or lien securing your claim. 5. Credits: The amount of all payments have been credited and deducted for the purposes of making this request for payment of administrative expenses. 6. Supporting Documents: Attach copies of supporting documents, such as purchase orders, invoices, itemized statements of running accounts, contracts as well as any evidence of perfection of a lien. DO NOT SEND ORIGINAL DOCUMENTS. If the documents are not available, explain. If the documents are voluminous, attach a summary. 7. Date-Stamped Copy: To receive an acknowledgment of the filing of your request, enclose a self-addressed envelope and copy of this request. Sign and print below the name and title, if any, of the creditor or other person authorized to file this request (attach copy of power of attorney, if any). _____________________________________________________ Penalty for presenting fraudulent claim: Fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §§ 152 and 3571.

T HIS S PACE I S F OR C OURT U SE O NLY

Date:

NOTE: The filing of this request will not result in the scheduling of a hearing to consider payment of your administrative claim but will result in the registry of your administrative claim with the Bankruptcy Court. If you wish to have a hearing scheduled on your claim, you must file a motion in accordance with Bankruptcy Rule 9013.
Local Form 24,new. 8/1/06.jml