IMPORTANT WARNING: A person who files a fraudulent claim could be fined up to $500,000, imprisoned for up to 5 years, or both. 18 U.S.C. §§ 152, 157, and 3571.
Read the instructions before filling out this form.
Filers must leave out or redact information that is entitled to privacy on this form or on any attached documents. Attach redacted copies of any documents that support the claim, such as promissory notes, purchase orders, invoices, itemized statements of running accounts, contracts, judgments, mortgages, and security agreements. Do not send original documents; they may be destroyed after scanning. If the documents are not available, explain in an attachment.
Fill in all the information about the claim as of the date the case was filed. That date is on the notice of bankruptcy (Form 309) that you received.
Federal Rule of Bankruptcy Procedure (FRBP) 2002(g)
Attach statement itemizing interest, fees, expenses, or other charges required by Bankruptcy Rule 3001(c)(2)(A). See Attachment Section below.
Nature of property:
A claim may be partly priority and partly nonpriority. For example, in some categories, the law limits the amount entitled to priority.
Check all that apply:
* Amounts are subject to adjustment on 04/01/25 and every 3 years after that for cases begun on or after the date of adjustment.
Attach redacted copies of any documents that show that the debt exists, a lien secures the debt, or both.
Also attach redacted copies of any documents that show perfection of any security interest or any assignment or transfers of the debt. In addition to the documents, a summary may be added. Federal Rule of Bankruptcy Procedure (called "Bankruptcy Rule") 3001(c) and (d). (See instructions and the definition of "redacted".)
Click below to attach documentation (see instructions) .
If you file this claim electronically, FRBP 5005(a)(2) authorizes courts to establish local rules specifying what a signature is.
I understand that an authorized signature on this Proof of Claim serves as an acknowledgment that when calculating the amount of the claim, the creditor gave the debtor credit for any payments received toward the debt.
I have examined the information in this Proof of Claim and have a reasonable belief that the information is true and correct.
I declare under penalty of perjury that the foregoing is true and correct.
You may, but are not required to, complete the "Optional Supplement to Official Form 410 for Use by Sexual Abuse Claimants" (the "Supplement") and submit it with your completed Official Proof of Claim Form. While you are not required to complete and file the Supplement to assert a claim against the Debtor, the Official Committee of Unsecured Creditors strongly recommends that any person asserting a sexual abuse claim fill out the Supplement in full and submit it with the Official Proof of Claim Form.
Please carefully read the Notice and Instructions that are included with this Supplement and respond to all applicable questions. If you have an attorney, you should complete this form with the assistance of counsel.
This Supplement and the information contained herein will be kept confidential under the Order Establishing Deadlines For Filing Proofs Of Claim And Approving The Form And Manner Of Notice Thereof entered by the United States Bankruptcy Court for the Northern District of California (the “Bankruptcy Court”).
However, this Supplement may be provided, pursuant to confidentiality procedures approved by the Bankruptcy Court, to the Debtor, the Committee, the Debtor’s insurers, their respective counsel, the United States Trustee, and to such other persons as the Bankruptcy Court may authorize on a confidential basis. In addition, this Supplement may be required to be disclosed to governmental authorities under mandatory reporting laws in many jurisdictions. If any such disclosure is made to a governmental authority, Sexual Abuse Claimants will be notified at the time of the disclosure of their Supplement.
A. Identity of Sexual Abuse Claimant
Mailing Address (If the Sexual Abuse Claimant is incapacitated, is a minor, or is deceased, provide the address of the individual submitting the claim. If you are in jail or prison, provide the address of your place of incarceration):
For communications regarding this claim you may use (check the appropriate options)
B. If you have hired an attorney relating to the Sexual Abuse described in this Supplement, please provide his or her name and contact information
For each of the questions listed below, please complete your answers to the best of your recollection.
Note: If you have previously filed a lawsuit about your Sexual Abuse in state or federal court, you must attach a copy of the complaint. If you have not filed a lawsuit, or if the complaint does not contain all of the information requested below, you should provide the information below to the extent of your recollection.
Please answer each of the following questions as best as you are able. If you do not know or recall an answer, you may indicate that you do not know or recall the answer and move on to the next question.
G. Please describe how you believe you were impacted, harmed, damaged, or injured as a result of the Sexual Abuse you described above. You can check the boxes, fill in the narrative, or both.
Please note that the boxes are not meant to limit the characterization or description of the impact(s) of your Sexual Abuse (Check all that apply).
If this box is checked, please also indicate your highest level of education completed or degree obtained:
Are you currently employed?
Are you currently married?
Have you ever been divorced?
Please describe the Sexual Abuse in as much detail as you can recall.
A. Prior Litigation.
Was a lawsuit regarding the Sexual Abuse you have described in this Supplement filed by you or on your behalf?
You are also required to attach a copy of any filed lawsuit.
If you previously filed a lawsuit, please indicate whether you filed a certificate of merit by checking the applicable option below
B. Prior Bankruptcy Claims
Have you filed any claims in any other bankruptcy case relating to the Sexual Abuse you have described in this Supplement?
You are required to attach a copy of any completed claim form.
C. Settlements
Have you settled any claim, lawsuit or any other formal or informal claim relating to the Sexual Abuse you have described in this Supplement?
You are required to attach a copy of any settlement agreement
D. Payments
Have you ever received any payment from the Debtor or any other person or entity on account of the Sexual Abuse you have described in this Supplement, including by having the Debtor pay for therapy you received on account of the Sexual Abuse you have described in this Supplement?
If you wish to attach additional documents to this Supplement, please use the Attachments sections above.
Check the appropriate option:
I have examined the information in this Supplement and have a reasonable belief that the information is true and correct.
I declare under penalty of perjury that the foregoing statements are true and correct.
Date: 1/19/2026
(if not signed by the Sexual Abuse Claimant)
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, 157, and 3571.