Free Response - District Court of Connecticut - Connecticut

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B-10 62¤525¤Oa~sie63:02-cv—01725-AWT Document 90-5 Filed 10/12/2006 Page 1 of 2
. MAIL COMPLETED FORM TO:
United States Bankruptcy Court
District of 1
ln re (Name of Debtor) Case Number
- - . , " .· » -
.;CJTT {ABL:. (OHHUNICATIONS “h}··5]•°IiE3·· w. Q ·` 9
NOTE: This form should not be used to make a claim for an administrative expense arising after the commencement of the __ I .. ,*ei`»` fr), O _
case. A request for payment of an administrative expense may be filed pursuant to 11 U.S.C. § 503. DR {·{·{IA_ r_ > -5. · U U {
Name of Creditor E _ `4 `:‘~ I ltjjii {’ gy , I V {
(The person or other entity to whom the debtor owes money or property) Check box if YOU are awaie that a"'YOn9 to [ S ile, {
, _ _ _ else has filed a proof of claim relating to NJN i
V"9'"'e Depenmem ef Texauen your claim. Attach copy or statement {
_ giving particulars. I
Name and Address Where Notices Should Be Sent {
CI Check box if you never received any {
Virginia Department of Taxation notices from the bankruptcy court in
Po. sex 2156 this Case- {
Richmond, VA 23218-2156
Cl Check box ir this address diners from THIS SPACE IS FOR {
4 _ _ _ the address on the envelope sent to you COURT USE ONLY l
Telephone No. ( BI.} H ] SI: 7*% PY NW9 COW? {
ACCOUNT OR OTHER NUMBER BY WHICH CFIEDITOFI IDENTIFIES DEBTOFI: Check here if this Claim lj {
._ . . , replaces
U DU j jaws E amends } a previously filed claim dated: {
1. BASIS FOR CLAIM {
Ij Goods sold KI Retiree benefits as defined in 11 U.S.C. § 1t14(a) I
I] Services performed EI Wages, salaries, and commissions (Fill out below)
Iii Money loaned Your social security number i
U Personal injury/wrongful death Unpaid compensation for services performed
IX] Taxes from to I
I] Other (Describe briefly) (date) { (date) {
2. DATE DEBT WAS INCURRED 3. IF COURT JUDGMENT, DATE OBTAINED {
See Attached N/A r
4. CLASSIFICATION OF CLAIM. Under the Bankruptcy Code all claims are classified as one or more of the following: (1) Unsecured nonpriority. (2) Unsecured Priority. {
(3) Secured. lt is possible for part of a claim to be in one category and part in another. I
CHECK THE APPROPRIATE BOX OR BOXES that best describe your claim and STATE THE AMOUNT OF THE CLAIM.
KI securzeo ci.AiM s Ki unsecunizo Pnionirv ci.AiM s }•3 5U •U *|]¤• Nb i
Attach evidence of perfection of security interest Specify tho priority ot tho oioirii
Brief Deeeripeen °I Ceuaiereli CI Wages, salaries, or commissions (up to $2,000, earned not more than 90
[I Root Estate ij Motor vshioio [I Othor (Describe) days before filing of the bankruptcy petition or cessation of the debtor’s I
business, whichever is earlier — 11 U.S.C. § 507(a)(3)) i
Amount of arrearage and other charges included in secured claim above if any ij Contributions to an employee benefit plan _ H U Slcl § 507(a)(4)
$ E Up to $900 of deposits toward purchase, lease, or rental of property or I
services for personal, family, or household use - 11 U.S.C. § 507(a)(6) F
I] UNSECURED NONPRIORITY CLAIMS $ IX] Taxes or penalties of governmental units — 11 U.S.C. § 507(a)(7)
A claim is unsecured if there is no collateral or lien on property of the debtor E Other ' 11 U·S·C· §§ 507(e)(2)· (exe) ' (Describe °'Ie"V) {
securing the claim or tothe extent that the value of such property is less than {
{ the amount of the claim. {
i
5. TOTAL AMOUNT OF » I
cLAiMArriiviE s s s ]•35U•U‘|]•*|b s 1•3SU•D'|]».*|L
CASE FILED: (Unsecured) (Secured) (Priority) e (Total)
El Check this box if claim includes prepetition charges in addition to the principal amount of the claim. Attach itemized statement of all additional charges.
6. CREDITS AND SETOFFS: The amount of all payments on this claim has been credited and deducted for the purpose of THiS SPACE is FOR
making this proof of claim. In filing this claim, claimant has deducted all amounts that claimant owes to debtor. COURT USE ONLY
7. SUPPORTING DOCUMENT: Attach copies of supporting documents, such as promissory notes, purchase orders, g
invoices, itemized statements of running accounts, contracts, court judgments, or evidence of security interest. If the
documents are not available, explain. If the documents are voluminous, attach a summary. ;
8. T|ME·STAMPED COPY: To receive an acknowledgment of the filing of your claim, enclose a stamped, self·addressed
envelope and copy of this proof of claim. l
Date; Sign and print the name and title, if any, of the creditor or other person authorized to file
this claim (attach copy of power of attorney, if any).
O 7 X B / I p I l g
O lj V * r
GARNETT P. TAYLOR- A6 NT
Pena/ty for Presenting Fraudulent C/aim: fine of up to $500, 000.00 or imprisonment for up to 5 years, or both. 18 U. S. C. §§ 152 and 3571.
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U · B_1&ase 3:02-cv-01725-AWT Document 90-5 Filed 10/12/2006 Page 2 Of 2
5205255
REV 10/95 CASE NUMBER
VIRGINIA DEPARTMENT OF TAXATION
P.O. BOX 2156 __
RICHMOND, VIRGINIA 23218-2155 :,8-Braga
I
SUMMARY OF UNPAID TAXES ASSESSED IN THE NAME OF I
I
SCuTT CABLE COMMUNICATIONS I
Total amount represents tax and Interest due.

ACCOJNT BILL TAX TAX PENALTY CLAIH I
NUMUER NUMBER CODE PERIOD AMOUNT AMOUNT g
I
0003273dbS 27712 CP 1101-110h $.00 $1.3¤1•808.78 f
0003273BbS 75883 NH 0000-0001 $.00 $11.50 I
0003273ALS 75061 Un 0000-0002 $.00 $11.M2 I
0EOJ2738b5 75013 UH 0000-0003 $.00 $11.30 g
00032735Lj 75615 wd 0000-0004 $.00 $11.2Q
0003273ésS 75615 NH 0000-0005 $.00 $11.15 Q
00052735bS 75817 UH 0000-000h $.00 $11.02 I
0003273éhS 75618 UH 0000-00u7 $.00 $10.1h I
00032736bS 75102 UH 0000-000é $.00 $10.67 I
00032735bS 75103 UH 0000-0001 $.00 $10.75 I
00u327ddb5 75105 JH 0000-0010 $.00 $10.bB g
0003273bb5 7510; UH 0000-0011 $.00 $10.51 2
0003273ébS 75107 UH 0000-0012 $.00 $10.47 .
0003273d&5 75113 0H 0000-0101 $.00 $10.¤1
00052730aS 75111 UH 0000-0102 . $.00 $10.32 `
TOTAL AMOUNT CLAIHED $1•3£0¤0H1.¤& 2
a·1.1.as7 ua 2-1.u101.1·1a 1.1 °°U”T· °“'G"*'A‘ 07/10/01-000001-01 T I