20-02145N

FIRST INSERTION
PROOF OF CLAIM FORM
IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT
IN AND FOR PINELLAS COUNTY, FLORIDA
Case No.: 20-002031-CI
In re:
ASSIGNMENT FOR BENEFIT OF CREDITORS
OF CFRA TRI-CITIES, LLC,
Assignor,
To:
J. TIM PRUBAN,
Assignee.
DEADLINE TO FILE IS
AUGUST 22, 2020

J. Tim Pruban
Focus Management Group
30725 U.S. Highway 19, PMB 330
Palm Harbor, Florida 34684
Telephone: 813-281-0062

1. NAME OF CREDITOR: ________________________________________

ADDRESS OF CREDITOR: _____________________________________

TELEPHONE NUMBER OF CREDITOR:___________________________

2. BASIS FOR CLAIM:
[ ]Goods Sold [ ] Wages, Salaries and Compensations
[ ]Services Performed [ ] Taxes
[ ]Money Loaned [ ] Other: ________________________

3. DATE DEBT WAS INCURRED: ________________________________

4. AMOUNT OF CLAIM: $ _____________________________________

5. SUPPORTING DOCUMENTS: Attach copies of supporting documents, such as promissory notes, purchase order, invoices, itemized statement of running accounts, court judgments, or evidence of security interests. If the documents are not available, explain. If the documents are voluminous, attach a summary.

6. SIGNATURE: Sign and print name and tide, if any, of the creditor or other person authorized to file this claim:


DATED: _____________, 2020 By: ______________________________
Signature of Claimant or Representative

Printed Name:______________________

May 1, 8, 15, 22, 2020 20-02145N

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