BI
Fom
3
PROOFOFCLAIM
District of Delaware
U].uTED STATES BANKRUPTCY CoURT
Name of Debtor:
Case Number:
FISKER AUTOMOTIVE, INC.
? -
i.-ii
I rt
1113086 (KG)
.J,'\lo{ 2
NOTE: Donotusethisformtomakeaclaimloranadminislrotiveexpensethatarisesafterthebankruptcyfiling.Yox,,
mayfile a request for payment ofan administrative expense according to I I U.S.C. S 50i.
.:a'
---r !
i._r_-.'
7
?t:.'it
),'ll,l. ,,.1 r.i: (' ,..i,r
r
. !;r,i,i,
Iir ritts .\$
LJj r ..
::j,l.j\iiilri(.\
r. tiLif:
,
Name of Creditor (the person or other entity to whom the debtor owes money or property):
Thg,r'ros {Turt
/t ytr
0
Name and address where notices should be sent:
I i':l{;u,:,
i.'*r,,*v,v'
Check this box
ifthis claim
previously filed claim.
amends a
Court Claim Number:
(If known)
Filed on:
Name and address where payment should be sent (ifdifferent fiom above)
Telephone number:
l'
email:
Amount of Claim
as of Date Case
Filed:
$ UNLIOUIDATED AMOUNT
If all or part ofthe claim
is secured, complete item 4.
If all or part ofthe clarm
is entitled to priority, complete item 5,
O Check this box
2.
3.
Basis for
Cl Check this box ifyou are aware that
anyone else has filed a proof of claim
relating to this claim. Attach copy of
statement giving particulars.
if the claim includes interest or other chrses in addition to the orinciDal amount of the claim. Attach
claim.
a statement that itemizes interest or charses
BREACH OF WARRANTY AND MAINTEMNCE AGREEMENTS
(See instruction #2)
Last four digits of any number
3a. Debtor may have scheduled account as:
by which creditor identifies debtor:
4. Secured Claim
(See instruction #4)
Check the appropriate box ifthe claim is secured by a lien on property or a right of
setoff, attach required redacted documents, and provide the requested information.
Nature of property or righi of setoff: OReal
Describe:
Value ofProperty:
Annual lnterest
Estate DMotor Vehicle OOther
S_
Rate_Yo
(when case was filed)
3b. Uniform Claim Identifier (optional):
Amount ofarresrege end other chirges,
included in secured claim, ifany:
or DVriable
Cl Domestic support obligations under I
$ 507 (a)(l)(A) or (a)(l)@).
I
Amount
D Wages, salaries, or commissions (up to $12,475r)
eamed within I 80 days before the case was filed or the
debtor's business ceased, whichever is earlier
u.s.c. g s07 (a)(a).
ll
O Up to $2,775* of deposits toward
purchase, lease, or rurtal ofproperty or
sewices for personal, family, or household
use- U.S.C. g s07 (a)(7).
ll
O
I
I
csse
wrs filed,
Basis for perfection:
-
Taxes or penalties owed to govemmental units
U.S.C. $ 507 (aX8).
-
Claim:
Unsecured:
5. Amount of Claim f,,ntitled to Priority under I I U.S.C. $ 507 (a). If any part of the claim falls into
the priority and st&te the amount
u.s.c.
ofthe time
s_
Amount of Secured
ClFixed
as
$
S
one of the following crtegories, check the box specifying
O Conhibutions to an
employee benefit plan
I I u.s.c. 0 507 (a)(s).
-
O Other
-
Specify
appl icable paragraph
I
Amount entitled to priority:
s
of
I U.S.C. $ 507 (aX_).
*Amounts are subject lo adjusttilent on 4/01/16 md ewry 3 years thereafter with respect to cases commenced on or after lhe darc of adjustmenl.
6. Credits. Theamountofallpaymentsonthisclaimhasbeencreditedforthepurposeofmakingthisproofofclaim.(Seeinstruction#6)
nq
''\t,
\TD
Bl0 (Official Form l0)
7. Documents:
(04/13)
missorynotes,purchaseorders,invoices,itemizedstatemmtsof
running accounts, contracts,judgments, mortgages, secunry agreements, or, in the case ofa claim based on an open-end or revolving consumer credit agfeement, a
Iftheclaimissecured,box4hasbeencompleted,andredactedcopiesofdocumentsproviding
statemintprovidingtheinformaiionrequiredbyfnen:001(oX3XA).
evidence ofperfection ofa security interest are-attached. Iftheclaim is secured by the debtor's principal residence, the Mortgage ProofofClaim Attachment is being
filed with this claim. (See instruction #7, md the definition of "rcdacled".)
DO NOT SEND ORIGINAL DOCUMENTS. ATTACHED DOCT]MENTS MAY BE DESTROYED AFTER SCANMNG.
If tte documents
are not available, ptease
explain:
DOCUMENTS
WLL BE PROVIDED UPON REQUEST
Check the appropriate box.
dl
am
thecreditor. D I am thecreditor'sauthorizedagent. 0 Iamthetsustee,orthe
debtor,
ii$?'j[l;L?iliili*
r
O Iamaguarantor,surety,indorser,orothercodebtor'
(See
Bankuptcv Rure 3005')
I declare under penalty of pe{ury that the information provided in this claim is true and correct to the best ofmy knowledge, infomation, and reasonable belief'
fllix,*u"'
Company:
Address and telephone number (if different from notice address abo
e
Telenhone
CN!L\,
nrrmber:
email:
Penalty for presenling fraudulent claim: Fine of up to $500,000 or imprisonment for up to 5 years, or both.
INSTRUCTIONS FOR PROOF OF
law. In certain circumstances, such as banloaptcy
The instructions dnd definitions below are general explmations of the
exceptions to these general rules may apply.
Court, Name of Debtor, and Case Number:
Fill in the federal judicial district in which the bankruptcy case was filed (for
example, Central District of California), the debtor's full name, and the case
number. Ifthe creditor received a notice ofthe case from the bankruptcy court,
all ofthis information is at the top ofthe notice.
l8 U.S.C. $0
cases not
152 and 3571.
filed vohtntaily by lhe debtor,
claim is entirely unsecured. (See Definitions.) Ifthe claim is securo4 check the
box for the nature and value of property that secures the olaim, attach oopies of lien
documentation, and state, as ofthe date ofthe bankruptcy filing, the annual interest
rate (and whether it is fixed or variable), and the amount past due on the claim.
Creditor's Name and Address:
Fill in the name ofthe person or entity asserting
Amount of Claim Entitled to Priority Under ll U.S.C. $ 507 (a).
If any portion of the claim falls into any category shom, check the appropriate
box(es) and state the amount entitled to priority. (See Definitions.) A claim may
be partly priority and partly non-priority. For example, in some ofthe categories,
the law limits the amount entitled to priority.
informed of its cunent address. See Federal Rule of Bankruptcy hocedure
(FRBP) 2002(g).
6. Credits:
An authorized signature on this proof of claim serves as an acknowledgment that
when calculating the amount ofthe claim, the creditor gave the debtor credit for
a claim and the name and
address of the person who should receive notices issued during the bankruptcy
cse. A separate space is provided for the payment address if it differs from the
notice address. The creditor has a continuing obligation to keep the court
1. Amount ofClaim as ofDate Case Filed:
State the total amount owed to the creditor on the date
ofthe bankruptcy filing.
Follow the instructions concerning whether to complete items 4 and
the box ifinterest or other charges are included in the claim.
2.
5.
Check
Basis for Claim:
ofdebt or how it was incurred. Examples include goods sold,
money Ioaned, services perfomed, personal injury/wrongful death, car loan,
mortgage note, and credit card. If the claim is based on delivering health care
goods or services, limit the disclosure ofthe goods or services so as to avoid
embanassment or the disclosure of confidential health cre infomation. You
may be required to provide additional disclosure if an interested party objects to
the claim.
State the type
3. Last Four Digits
of Any Number by Which Creditor Identifies Debtor:
State only the last four digits of the debtor's account or other number used by the
creditor to identify the debtor.
3a, Debtor May Have Scheduled Account As:
Report a change in the creditor's name, a transfened claim, or any other
infomation that clarifies a difference beween this proof of claim and the claim
as scheduled by the debtor.
3b. Uniform Claim ldentifier:
Ifyou
use a uniform claim identifier, you may report it here. A miform claim
identifier is an optional 24-character identifier that certain large creditors use to
facilitate electronic payment in chapter l3 cases.
Check whether the claim is fullv or
secured. Skio this section
ifthe
5.
any payments received toward the debt.
7.
Documents:
Attach redacted copies ofany documents that show the debt exists and a lien
secures the debt. You must also attach copies of documents that evidence perfection
ofany security interest and documents required by FRBP 3001(c) for claims based
on an open-end or revolving consumer credit agreement or secured by a security
interest in the debtor's principal residence. You may also attach a summary in
additiontothedocumentsthemselves.FRBP300l(c)and(d). Iftheclaimisbased
on delivering health care goods or services, limit disclosing confidential health care
infomation. Do not send original documents, as attachments may be destroyed
after scanning.
8,
Date and Signature:
The individual completing this proof of claim must sign and date it. FRBP 901 l.
Ifthe claim is filed electronically, FRBP 5005(a)(2) authorizes courts to establish
local rules specifying what constitutes a siSnature. If you sign this fom, you
declare under penalty of perjury that the information provided is hue and conect to
the best of your knowledge, information, and reasonable belief. Your sigpature is
also a certification that the claim meets the requirements of FRBP 90ll@).
Whether the claim is filed electronically or in person, if your name is on the
signature line, you are responsible for the declaration. Print the name and title, if
any, of the creditor or other person authorized to file this claim. State the filer's
address and telephone number ifit differs from the address given on the top ofthe
form for purposes ofreceiving notices. Ifthe claim is filed by an authorized agent,
provide both the name of the individual filing the claim and the name of the agent.
Ifthe authorizBd agent is a seruicer, identify the corporate servicer as the company.
Criminal penalties apply for making a false statement on a proof ofclaim.