Case 13-02872-JMC-13 Claim 17-1 Filed 06/15/13 Pg 1 of 3

B 10 (Ofcial Fonn 10)(12112)

UNITED STATES BANKUPTCY COURT SOUTHERN District Of INDIANA PROOF OF CLAIM
Name ofDebtor: Case Number:
GARY TAGUE 13-02872
NOTE: Do not use this form to mk a claim/or an administrative epense that arises after the bankuptc filing. You
ma fie a request for pament of an administrative expense according to 11 US.C. 503.
Name of Creitor (the person or other entity to whom the debtor owes money or property):
Jefferson Capital Systems, LLC; Purchased From RJM Acquisitions, LLC
COURT USE ONLY
Name and address where notices should be sent:
0 Check this box if this claim amends a
Jefferson Capital Systems, LLC
previously filed claim.
PO BOX7999
SAINT CLOUD, M 56302-9617 Court Claim Number:
(I kown)
Telephone number: 800-928-7314 email: Bankruptcy@etTersonCapitallntemational.com
File on:
Name and address where payment should be sent (if different fom above):
D Check this box if you are aware that
Jefferson Capital Systems, LLC
anyone else has fled a proof of claim
PO BOX 953185
relating to this claim. Attach copy of
ST LOUIS, MO 63195-3185 statement giving particular.
Telephone number: 800-928-7314 email: Bankruptcy@eff ersonCapita!Intemational. com
I. Amount of Claim as of Date Case File: $ 104.98
If all or part of the claim is secure, complete item 4.
If all or par of the claim is entitle to priority, complete item 5.
0 Check this box if the claim includes interet or other charges in addition to the principal amount of the claim. Attach a statement that itemizes interest or charges.
2. Basis for Claim: TELECOM
(Se instruction#2)
3. Last four digit of any number 3a. Debtor may have scheduled account as: 3b. Uniform Claim ldentifer{optional):
by which creditor identifes debtor:
5455
DIRECTV JCPBKR13028721NS00005455
(Se instruction #3a) (See instruction #3b}
Amount of arrearage and other charges, as of the time case was filed,
4. Secured Claim (See instruction #4) included in secured claim, if any:
Check the appropriate box if the claim is secure by a lien on property or a right of
setoff, attach required reacted documents, and provide the reuested information. $
Nature of property or right of setoff: OReal Estate D Motor Vehicle OOther Basis for perfetion:
Describe:
Value of Property:$ Amount of Seured Claim: $
Annual Interet Rate _ % OFixed or OVariable
Amount Unsecured: $
(when case was filed)
5, Amount of Claim Entitled to Priority under 11 U.S.C. 507 (a). If any part of the claim falls into one of the following categorie, check the box specifying
the priority and state the amount.
0 Domestic support obligations under 11 0 Wages, salarie, or commissions (up to $11,725*) 0 Contributions to an
U.S.C. 507 (aXl)(A) or (a)(l)(B). eared within 180 days before the case w fle or the employee beneft plan-
debtor's business cesed, whichever is earlier- 11 U:S.C. 507 (a)(5).
II U.S.C. 507 (a)(4). Amount entitled to priority:
0 Up to $2,600* of deposits toward 0 Taxes or penaltie owed to govermentl units- 0 Other-Speif
$
purchase, lease, or rntal of property or 11 U.S.C. 507 (a)(8). applicable paragraph of
services for personal, family, or household II U.S.C. 507 (a)( ).
use- II u:s.c. 507 (aX7).
*Amounts are subject to austment on 411113 and every 3 years thereafter with resect to cases commenced on or after the dte of adutment.
6. Credits. Te amount of all payments on this claim has been credited for the purpose of making this proof of claim. (See instrction #6)
Case 13-02872-JMC-13 Claim 17-1 Filed 06/15/13 Pg 2 of 3
B I 0 (Official Fonn I 0) (12/12) 2
7. Documents: Attached are redacted copies of any documents that support the claim, such as promissory notes, purchase orders, invoices, itemized statements of
running accounts, contacts, judgments, morgages, securit agreements, or, in the case of a claim base on an open-end or revolving consumer credit agreement, a
statement providing the infonnation require by FRBP 300I(c)(3)(A). If the claim is secured, box4 has been completed, and redacte copies of documents providing
evidence of perfection of a securit interest are attached. If the claim is secure by the debtor's principal residence, the Mortgage Proof of Claim Attachment is being
fled with this claim. (ee instruction #7, and the defnition of"redacted".
DO NOT SEND ORIGINAL DOCUMENTS. A T ACHED DOCUMENTS MAY BE DESTROYED AFTER SCANNING.
If the documents are not available, please explain:
8. Signature: (See instruction #8)
Check the appropriate box.
I am the creitor. 0 I am the creditor's authorized agent. 0 I am the trustee, or the debtor,
or their authorized agent.
(See Bankruptcy Rule 3004.)
L I am a guarantor, suret, indorser, or other codebtor.
(Se Bankruptcy Rule 3005.)
I declare under penalty of perjury that the infonnation provided in this claim is true and corret to the best of my knowlege, information, and reasonable belief.
Print Name: .ohnathan Kirby
Title: Director of Bankruptcy
Company: Jefferson Capital Systems LLC
Addres and telephone number (if different from notice address above):
I elephone number: email:
Isl Johnathan Kirby June 12, 2013
(Sigature) (Date)
7enmr presentinEaUntCim: Tine ot up to ::uu,uuu or 1mpnsonmenfThr up to : years, o us I:L ii , 11.
Case 13-02872-JMC-13 Claim 17-1 Filed 06115/13 Pg 3 of 3

Account Statement Summar

Account Number:X-X-X-5455
c '
A
cc
o
unt Statemen
t
Summ
a
ry Created: 6/12/2013
BFRAME B2 System
BKRPOD Page
Bankruptcy Proof of Debt
Tracking# JCAP2906474648
Clnt# XXXXXXXXXXXX5455
client RJMPUR RJMPUR
Status BANKRUPTCY 11/11/2011
Name TAGUE, GARY
ADl 221 E EAGLE DR
A02
City NINEVEH
State IN 46164
Language
Bankruptcy
case Number
Date Filed
chapter 13
Note Info
Info
13-02872 source
03/26/2013 court
single Debtor
Account Inactive
ADDRESS OK
Home XXXXXX1310
Work XXXXXX
Alt XXXXXXOOOO
SSN XXX/XX/0000
DOB
GUI
057
Dispo code
Note Date 02/12/1998 Amount 104.98
writeoff Date 08/09/1999 Amount 0.00
orig Date 02/12/1998 Amount 104.98
BALANCE
Placed
Paid
Balance
DATES
Placed Date
Last worked
MISC
Desc2 07009111
Desc3 1009748295
Desc4
104.98
0.00
104.98
11/11/2011
00/00/0000
HISTORY AT CONVERSION
Tot Interest
Prior Paid
0.00
0.00
---------------------------A
cc
ount Infr
ma
ton---------------------------
Purchased From: RJM ACQUISITIONS, LLC
Debt originated From: DIRECTV
Last Transaction Date: 08/09/1999
charge-off Date: 08/09/1999
Last Payment Date:
Last Purchase Date:
--------------------------- Oth
e
r Infor
ma
to
n
-----------------------------
Reference Number for Payment Processing: 2906474648
BALANCE at TIME OF FILING: $104. 98 case Number:13-02872
open Date:OZ/12/1998 claim Amount: $104.98
Interest: $0.00
Fees:
Principal Balance:$104.98
No post charge-off interest, fees, or other charges included in the claim
PAYENT ADDRSS
Jeferson Capital Systems, LLC
PO BOX 953185
ST LOUIS, MO 63195-3185