File a Confidential Survivor Proof Of Claim

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.

Part 1: Identify the Claim

1. Who is the current creditor?
2. Has this claim been acquired from someone else?

3. Where should notices and payments to the creditor be sent?

Federal Rule of Bankruptcy Procedure (FRBP) 2002(g)

4. Does this claim amend one already filed?

5. Do you know if anyone else has filed a proof of claim for this claim?

Part 2: Give Information About the Claim as of the Date the Case Was Filed

6. Do you have any number you use to identify the debtor?

7. How much is the claim?
Does this amount include interest or other charges?

8. What is the basis of the claim?
9. Is all or part of the claim secured?

10. Is this claim based on a lease?

11. Is this claim subject to a right of setoff?

12. Is all or part of the claim entitled to priority under 11 U.S.C. § 507(a)?

A claim may be partly priority and partly nonpriority. For example, in some categories, the law limits the amount entitled to priority.

Attachments / Documents

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".)

Attachments:
  • Necessary documentation can be attached to the Proof of Claim before the information for the form is submitted
  • Attachments to the Proof of Claim are required to be PDF files.
  • Multiple attachments to the Proof of Claim are permitted.
  • Do not upload a completed Proof of Claim form as an attachment to this filing. Attaching a completed Proof of Claim will result in multiple versions of the form being filed (the electronically created proof of claim form plus the proof of claim attached). If filing an Amended Proof of Claim, the attachment of the previously filed claim is allowed.

Click below to attach documentation (see instructions) .

Attach…

Part 3: Sign Below

The person completing this proof of claim must sign and date it. FRBP 9011(b).

If you file this claim electronically, FRBP 5005(a)(2) authorizes courts to establish local rules specifying what a signature is.

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.
Select the appropriate option:

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.

Executed on date 9/6/2025

Print the name of the person who is completing and signing this claim:

You are strongly encouraged to also complete a voluntary Confidential Survivor Supplement ("Supplement"). Submitting the completed Supplement at the outset will help streamline the process of identifying claims and all applicable insurance and expedite distribution to creditors.

Confidential Survivor Supplement

Please carefully read the Notice and Instructions that are included with this CONFIDENTIAL SURVIVOR PROOF OF CLAIM and respond to all applicable questions. If you have an attorney, you should complete this form with the assistance of counsel.

Part 1: Confidentiality

The information you share will be kept strictly confidential. This form and the information in it may be provided, pursuant to confidentiality procedures approved by the Bankruptcy Court, to the RCBSR, certain insurers of the RCBSR, the Official Committee of Unsecured Creditors, the United States Trustee, and to such other persons as the Bankruptcy Court may authorize. Please be assured that these parties have agreed and are required to keep your information strictly confidential.

Part 2: Identifying Information

A. Survivor Claimant

(If party is incapacitated, is a minor or is deceased, please provide the address of the individual submitting the claim. If you are in jail or prison, your current address)

Telephone No(s):

May we leave voicemails for you regarding your claim?

May we send confidential information to your email?

Gender

B. Survivor Claimant’s Attorney (if any)

Part 3: Nature of Complaint

Note: If you have previously filed a lawsuit against The Roman Catholic Bishop of Santa Rosa, aka Diocese of Santa Rosa (“RCBSR”) in state or federal court, you may attach the complaint. If you did not file a lawsuit, or if the complaint does not contain all of the information requested below, you must provide the information below.

As to claims involving multiple perpetrators, this part must be answered separately as to any claimant alleging abuse by one or more RCBSR affiliated perpetrators. Part 4 must be answered separately for each complaint related to separate RCBSR affiliated perpetrators.

i. If subsequent wrongful conduct by the RCBSR or its employees or officials caused you further trauma directly or indirectly related to the abuse state

Part 4: Impact of Abuse

Where more than one perpetrator is alleged, please answer the questions separately as to each perpetrator.

Part 5: Additional Information

a. Prior Bankruptcy Claims

Have you, or has anyone on your behalf, filed any claims in any other bankruptcy case relating to the abuse described in this claim?

If “Yes,” you are required to attach a copy of any completed claim form

b. Prior Non-Bankruptcy Claims

Have you, or has anyone on your behalf, asserted or filed any claim or lawsuit seeking damages for the abuse described in this claim?

Please attach a copy of any complaint in such lawsuit.

c. Settlements

Regardless of whether a complaint was ever filed against any party because of any abuse as described in this claim, have you settled any claim relating to abuse described in this claim?

You are required to attach a copy of any settlement agreement

d. Bankruptcy

Have you ever filed bankruptcy?

If "Yes," please provide the following information

Attachments / Documents

If you wish to attach additional documents to this Confidential Survivor Supplement, please use the Attachments sections above.

Signature

Sign and print your name. If you are signing the claim on behalf of another person or an estate, print your title.

Under penalty of perjury, I declare the foregoing statements to be true and correct.

Date: 9/6/2025

Relationship of signer to party on behalf of whom claim is being made: (such as parent, family member, guardian, attorney, executor of estate

Acknowledge you are a human

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.