THIS PROOF OF CLAIM IS TO BE FILED WITH THE RECEIVER. DO NOT FILE THIS FORM WITH
THE COURT OR CONTACT THE COURT WITH ANY QUESTIONS YOU MAY HAVE.
PROOF OF CLAIM FORM
FOR RECEIVER'S USE ONLY
SEC v. Platinum Management (NY)
LLC, et al., Case No. 16-CV-6848
(U.S. Dist. Ct. E.D.N.Y.)
Claim No: ____________________
Date of Claim:
/
/
This Proof of Claim Form is only for the use of creditors of the Platinum funds now under the
receivership of Bart M. Schwartz. It is not for the use of investors in the funds or those who have
unpaid redemptions.
PART I: CLAIMANT IDENTIFICATION
Last Name
M.I.
First Name
Company Name
DBA (If applicable)
Social Security Number
—
Taxpayer Identification Number
—
Telephone Number (Work)
—
—
or
Telephone Number (Home)
—
—
—
Email Address
Address
MAILING INFORMATION
Address (continued)
City
Foreign Province
State
Foreign Postal Code
FOR CLAIMS
PROCESSING
ONLY
Zip Code
Foreign Country Name/Abbreviation
FOR CLAIMS
PROCESSING
ONLY
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PART II. PLATINUM RECEIVERSHIP ENTITIES
Identify, by filling in the appropriate circle, the Receivership Entity against whom this claim is filed.
RECEIVERSHIP ENTITIES:
A. Platinum Credit Management, L.P.
B. Platinum Partners Credit Opportunities Master Fund L.P.
C. Platinum Partners Credit Opportunities Fund (TE) LLC
D. Platinum Partners Credit Opportunities Fund LLC
E. Platinum Partners Credit Opportunity Fund (BL) LLC
F. Platinum Liquid Opportunity Management (NY) LLC
G. Platinum Partners Liquid Opportunity Fund (USA) L.P.
H. Other (please identify)
PART III. CREDITOR CLAIM
Select one claim type from the below options by filling in the appropriate circle.
(Note: A separate Proof of Claim must be filed for each claim type).
TYPE OF CLAIM:
A. Services Claim
B. Loan Claim
C. Tax Claim
D. Judgment Creditor Claim
E: Employment Compensation Claim (fill out below)
Unpaid compensation for services performed from:
MM DD
/
Y YYY
/
MM
/
to
DD
/
YYYY
F: Other Claim: __________________________________
(Please describe or attach pages to additional information)
SECURED CLAIM:
Secured Party. Fill in the circle if you contend your claim is subject to a security interest. Attach copies of all documents
that evidence the claim of secured status, including promissory notes, mortgages, security agreements, and evidence of
perfection of lien.
ASSERTED VALUE OF COLLATERAL:
If Court Judgment, Date Obtained:
M
M
D
/
D
Y
/
Y
.
$
DESCRIPTION OF COLLATERAL:
Y
00
If Legal Action Pending, Date Commenced, Court Name, and Case No.:
Y
M
M
D
D
/
Y
Y
Y
Y
/
TOTAL AMOUNT OF CLAIM:
$
2
.
00
PART IV. QUESTIONS
If you require additional space to respond to the questions below, attach extra schedules in the same format as below.
Please fill in the circle below if the question applies.
1. If the claimant is an entity, attach a list of all persons who directly or indirectly hold beneficial interests in the claimant
exceeding ten percent (10%).
Last Name
First Name
2. Was, or is, the claimant (or the holder of any direct or indirect beneficial interest in the claimant) ever an officer,
director or employee of Platinum Partners or any of its affiliated entities? If so, please identify the individual, the
entity for which s/he worked, provide the dates of the employment or work, title and responsibilities.
3. Was, or is, the claimant (or the holder of any direct or indirect beneficial interest in the claimant) related in any
way to any current or former officer, director or employee of Platinum Partners or any of its affiliated entities? If so,
please identify the individual, the name of the current or former officer, director or employee of Platinum Partners or any
of its affiliated entities, the nature of the relationship and if known, the dates of his/her employment or work and title.
YOU MUST SIGN THE DECLARATION ON THE FOLLOWING PAGE. FAILURE
TO SIGN THIS PROOF OF CLAIM FORM MAY RESULT IN A DELAY IN
PROCESSING OR THE REJECTION OF YOUR CLAIM.
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PART V. DECLARATIONS & SIGNATURE
SUPPORTING DOCUMENTATION: Please attach to your Proof of Claim Form all documents that support your Claim. Such
documentation may include, but is not limited to: copies of all agreements, promissory notes, purchase orders, invoices, itemized
statements of running accounts, contracts, court judgments, mortgages, security agreements, evidence of perfection of lien; and
other documents evidencing the amount and basis of the claim. DO NOT SEND ORIGINAL DOCUMENTS. If such
documentation is not available, please attach an explanation of why the documents are unavailable.
Please do not submit the following types of materials with your Proof of Claim Form unless requested by the Receiver: (1)
marketing brochures and other marketing materials received from Receivership Entities; (2) routine or form correspondence received
from Receivership Entities; (3) copies of pleadings on file in any case involving the Receiver or the Receivership Entities; and (4)
other documents received from Receivership Entities that do not reflect Claimant specific information concerning the existence or
value of a Claim.
VERIFICATION OF CLAIMS: All Proof of Claim Forms filed are subject to verification by the Receiver and approval by the District
Court for the Eastern District of New York (the "Court"). It is important to provide complete and accurate information to
facilitate this effort. Claimants may be asked to supply additional information to complete this process.
CONSENT TO JURISDICTION: By submitting a Proof of Claim Form in this case, you consent to the jurisdiction of the Court for all
purposes related to this claim and agree to be bound by its decisions, including, without limitation, a determination as to the
validity and amount of any claims asserted against the Receivership Entities. By submitting a Proof of Claim Form, you agree to
be bound by the actions of the Court even if that means your claim is limited or denied.
I (WE) DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES OF AMERICA THAT ALL OF
THE FOREGOING INFORMATION SUPPLIED ON THIS PROOF OF CLAIM FORM BY THE UNDERSIGNED IS TRUE AND
CORRECT TO THE BEST OF MY (OUR) KNOWLEDGE.
_____________________________________________
(Sign your name here)
_____________________________________________
(Date)
_____________________________________________
(Type or print your name here)
_____________________________________________
(Capacity of person(s) signing, e.g.,
Acquirer, Executor or Administrator)
Submit your Proof of Claim Form and supporting documentation by:
(i) electronic mail, as an attachment in portable document form (.pdf) to [email protected];
or
(ii) mail, to Platinum Partners, 1325 Avenue Of the Americas, Suite 2717, New York, NY 10019, Attn: Claims Dept.
Reminder Checklist:
5. If you have questions concerning the filing or processing of
this Proof of Claim Form, please contact the Receiver at
[email protected] or (212) 582-2222.
1. Please sign the above declaration.
2. Remember to attach supporting documentation, if available.
6. If you submit your claim by email, you should receive an
automated reponse indicating that your proof of claim has
been received. If not, please call 212-582-2222.
3. Keep a copy of your claim form and all supporting
documentation for your records.
4. If your contact information changes, please send an
email to [email protected]
7. If you submit your claim by mail and would like to receive an
acknowledgment of the filing of your claim, enclose a
stamped, sef-addressed envelope and copy of this Proof of
Claim Form.
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