UN GSE - Office of Military Settlement 305 North Second Avenue #253, Upland, California. T.U.S.A.

www.ungse.org/oms.html
UN-GSE OMS Form 100 (Rev. 05.02.2014)







OFFICE OF MILITARY SETTLEMENT
CREDITOR CLAIM FORM

Please Mail the original signed and notarized form (copies, emails and
faxes not accepted. For your protection, you are encouraged to send your
claim by certified mail, with return receipt requested) to the address
below:

Address: Office of Military Settlement
UN GSE (OMS)
305 North Second Avenue #253
Upland, California
The United States of America

Reminder: Please make a copy of your filing for your own records.



UN GSE - Office of Military Settlement 305 North Second Avenue #253, Upland, California. T.U.S.A.
www.ungse.org/oms.html
UN-GSE OMS Form 100 (Rev. 05.02.2014)

Creditor Claim
Reserve for Filing Stamp

Claim No.: ___________________
To Public Franchise(s) or Underlying Estate(s)
1. All claims for liability/debt must arrive in this office before
June 1, 2014 A.D.
2. Read entire claim before filing. ONLY AND ORIGINAL
CREDITOR CLAIM is acceptable.
3. This claim form must be duly verified by authorized signatory.
4. All Claimants must prove their bona fides.
5. Attach separate sheets as necessary.
6. Fill out in duplicate. One copy to be retained by claimant.
7. Claim must be mailed to: Office of Military Settlement,
UN GSE, 305 North Second Avenue #253, Upland, California
To: Office of Military Settlement (OMS)
Name of Claimant (Note: Claimant is a PUBLIC OFFICER, EMPLOYEE, heir, beneficiary,
creditor, contingent creditor, or other person claiming to have standing in the administration of
a PUBLIC FRANCHISE(S) or underlying ESTATE(S), or both and has attached proof of bona
fides to this claim form):
Address of Claimant:
Federal/State Registry/EIN/DUNS or other identifying number(s)(proof of authority must be
attached):
Claimants telephone number:
In the Matter of (Name of Public Franchise or Underlying Estate claim is against):
Identifying Number of Public Franchise or Underlying Estate:
Address of Public Franchise or Underlying Estate:
Nature of claim (include as much detail as possible, if claim is for services rendered provide
copy of contract):
UN GSE - Office of Military Settlement 305 North Second Avenue #253, Upland, California. T.U.S.A.
www.ungse.org/oms.html
UN-GSE OMS Form 100 (Rev. 05.02.2014)

Creditor Claim for Settlement of Liabilities
To Public Franchise(s) or Underlying Estate(s) (Continued)
The undersigned PUBLIC OFFICER, EMPLOYEE, heir, beneficiary, creditor, contingent
creditor, or other person claiming to have standing in the administration of a PUBLIC
FRANCHISE(S) or underlying ESTATE(S), or both is a duly authorized agent of the same in
this behalf, being duly sworn, deposes and says that:
1. __________________________________________ (Name of PUBLIC FRANCHISE(S)
or underlying ESTATE(S), or both)is justly and truly indebted to ___________________
____________________________________________________________ in the amount
of _______________________________________________________ with interest and
penalty as shown in the attached itemized true bill/verified accounting.
2. This debt is for ___________________________________________________________
__________________________________________________________________ under
the_______________________________________________________laws/contract of
________________________________________________________________________
(please attach certified proof of authority)
3. No part of this debt has been paid or discharged by any means, and is now due and
payable to
________________________________________________________________________
4. Certified copies of any/all liens, securities, judgments, other evidences of debt are duly
attached hereto.
5. No note or other negotiable instrument has been received for payment of this debt or any
part of it, nor has any other claims, including insurance claims been made elsewhere to
collect this debt, or any part thereof.
6. This debt does does not have priority. Bases of priority: _______________________
________________________________________________________________________

(Notarize)

Subscribed and Sworn to Before Me On Signature
Title ID Number
Month Day Year Address
Telephone Number
(jurat/seal)