Fill in this information to identify your case:
`
`Debtor 1
`
`________________________________________________________________
`Debtor 2
`(Spouse, if filing) First Name
`Last Name
`Middle Name
`
`Anthony Scott Levandowski
`__________________________________________________________________
`Last Name
`First Name
`Middle Name
`
`United States Bankruptcy Court for the: ______________________ District of __________
`Northern District of California
`(State)
`
`Case number ___________________________________________
`20-30242
` (If known)
`
` Check if this is an
`amended filing
`
`Official Form 104
`For I ndividua l Cha pt e r 1 1 Ca se s: List of Cre dit ors Who H a ve t he 2 0 La rge st
`U nse c ure d Cla im s Aga inst Y ou a nd Are N ot I nside rs
`12/15
`
`If you are an individual filing for bankruptcy under Chapter 11, you must fill out this form. If you are filing under Chapter 7, Chapter 12, or
`Chapter 13, do not fill out this form. Do not include claims by anyone who is an insider. Insiders include your relatives; any general partners;
`relatives of any general partners; partnerships of which you are a general partner; corporations of which you are an officer, director, person in
`control, or owner of 20 percent or more of their voting securities; and any managing agent, including one for a business you operate as a sole
`proprietor. 11 U.S.C. § 101. Also, do not include claims by secured creditors unless the unsecured claim resulting from inadequate collateral
`value places the creditor among the holders of the 20 largest unsecured claims.
`Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct
`information.
`
`Pa rt 1 :
`
`List t he 2 0 U nse cure d Claim s in Orde r from La rge st t o Sm alle st . Do N ot I nc lude Cla im s by I nside rs.
`
`1
`
`2
`
`Google LLC
`__________________________________________
`Creditor’s Name
`
`Keker, Van Nest & Peters LLP
`__________________________________________
`Number
`Street
`
`633 Battery Street
`__________________________________________
`
`94111-1809
`CA
`San Francisco
`__________________________________________
`City
`State
`ZIP Code
`
`Robert A. Van Nest, Esq.
`__________________________________________
`Contact
`
`____________________________________
`Contact phone
`
`Ramsey & Ehrlich LLP
`__________________________________________
`Creditor’s Name
`
`__________________________________________
`Number
`Street
`803 Hearst Avenue
`__________________________________________
`
`94710
`CA
`Berkeley
`__________________________________________
`City
`State
`ZIP Code
`
`Miles Ehrlich, Esq.
`__________________________________________
`Contact
`
`____________________________________
`Contact phone
`
`What is the nature of the claim? ____________________________
`Judgment Liens
`
`179,047,999.00
`$____________________________
`
`Unsecured claim
`
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`
`$_____________________
`
`Unsecured claim
`
`$_____________________
`
`✔✔
`✔✔✔
`
`What is the nature of the claim? ____________________________
`Legal
`
`3,000,000.00
`$____________________________
`
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`
`$_____________________
`
`Unsecured claim
`
`$_____________________
`
`Case: 20-30242 Doc# 3 Filed: 03/04/20 Entered: 03/04/20 16:37:28 Page 1 of 6
`28
`For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims
`Official Form 104
`
`page 1
`
`✔
`

`

`Debtor 1
`
`Anthony Scott Levandowski
`_______________________________________________________
`Last Name
`First Name
`Middle Name
`
`20-30242
`Case number (if known)_____________________________________
`
`Income Taxes
`What is the nature of the claim? ____________________________
`
`225,000.00
`$____________________________
`
`Unsecured claim
`
`3 __________________________________________
`Internal Revenue Service
`Creditor’s Name
`P.O. Box 7346
`__________________________________________
`Number
`Street
`
`__________________________________________
`
`PA
`Philadelphia
`19101-7346
`__________________________________________
`City
`State
`ZIP Code
`
`__________________________________________
`Contact
`
`____________________________________
`Contact phone
`
`4 __________________________________________
`
`Franchise Tax Board
`Creditor’s Name
`Personal Bankruptcy MS A340
`__________________________________________
`Number
`Street
`PO Box 2952
`__________________________________________
`
`CA
`95812-2952
`Sacramento
`__________________________________________
`City
`State
`ZIP Code
`
`__________________________________________
`Contact
`
`____________________________________
`Contact phone
`
`5 __________________________________________
`Finemann PR
`Creditor’s Name
`
`__________________________________________
`Number
`Street
`
`530 Bush Street #403
`__________________________________________
`
`94108
`CA
`San Francisco
`__________________________________________
`City
`State
`ZIP Code
`
`Michael Finemann
`__________________________________________
`Contact
`
`____________________________________
`Contact phone
`
`6 __________________________________________
`Protector Boats Service Center
`Creditor’s Name
`
`__________________________________________
`790 National Court
`Number
`Street
`
`__________________________________________
`
`94804
`CA
`Richmond
`__________________________________________
`City
`State
`ZIP Code
`
`__________________________________________
`Contact
`
`____________________________________
`Contact phone
`
`7 __________________________________________
`
`Chase
`Creditor’s Name
`P.O. Box 15298
`__________________________________________
`Number
`Street
`
`__________________________________________
`
`DE
`Wilmington
`19850-5298
`__________________________________________
`City
`State
`ZIP Code
`
`__________________________________________
`Contact
`
`____________________________________
`Contact phone
`
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`Unsecured claim
`
`$_____________________
`
`$_____________________
`
`Income Taxes
`What is the nature of the claim? ____________________________
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`Unsecured claim
`
`$_____________________
`
`$_____________________
`
`Personal Services
`What is the nature of the claim? ____________________________
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`Unsecured claim
`
`$_____________________
`
`$_____________________
`
`What is the nature of the claim? ____________________________
`Personal Services
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`Unsecured claim
`
`$_____________________
`
`$_____________________
`
`✔ ✔✔✔✔✔✔✔✔
`✔✔✔✔
`
`75,000.00
`$____________________________
`
`34,000.00
`$____________________________
`
`$____________________________
`19,502.00
`
`3,900.00
`$____________________________
`
`$_____________________
`
`page 2
`
`What is the nature of the claim? ____________________________
`Credit Card Debt
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`Unsecured claim
`$_____________________
`Case: 20-30242 Doc# 3 Filed: 03/04/20 Entered: 03/04/20 16:37:28 Page 2 of 6
`29
`For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims
`Official Form 104
`
`✔
`

`

`Debtor 1
`
`Anthony Scott Levandowski
`_______________________________________________________
`Last Name
`First Name
`Middle Name
`
`20-30242
`Case number (if known)_____________________________________
`
`8 __________________________________________
`Stefanie Olsen
`Creditor’s Name
`
`__________________________________________
`Redacted
`Number
`Street
`
`__________________________________________
`
`__________________________________________
`City
`State
`ZIP Code
`
`__________________________________________
`Contact
`
`____________________________________
`Contact phone
`
`9 __________________________________________
`Wells Fargo
`Creditor’s Name
`
`__________________________________________
`PO Box 10347
`Number
`Street
`
`__________________________________________
`
`50306-0347
`IA
`Des Moines
`__________________________________________
`City
`State
`ZIP Code
`
`__________________________________________
`Contact
`
`____________________________________
`Contact phone
`
`10 __________________________________________
`
`Apple Pay
`Creditor’s Name
`
`Lockbox 6112(cid:0)PO Box 7247
`__________________________________________
`Number
`Street
`
`__________________________________________
`
`19170-6112
`PA
`Philadelphia
`__________________________________________
`City
`State
`ZIP Code
`
`__________________________________________
`Contact
`
`____________________________________
`Contact phone
`
`11 __________________________________________
`Goodwin Procter LLP
`Creditor’s Name
`
`__________________________________________
`Number
`Street
`
`__________________________________________
`601 Marshall Street
`
`94063
`CA
`__________________________________________
`Redwood City
`City
`State
`ZIP Code
`
`__________________________________________
`Neel Chatterjee, Esq.
`Contact
`
`____________________________________
`Contact phone
`
`12
`
`Uber Technologies, Inc.
`__________________________________________
`Creditor’s Name
`
`Boies Schiller Flexner LLP
`__________________________________________
`Number
`Street
`1401 New York Ave, NW
`__________________________________________
`
`20005
`DC
`Washington
`__________________________________________
`City
`State
`ZIP Code
`
`Domestic Support Obligations
`What is the nature of the claim? ____________________________
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`Unsecured claim
`
`$_____________________
`
`$_____________________
`
`Credit Card Debt
`What is the nature of the claim? ____________________________
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`Unsecured claim
`
`$_____________________
`
`$_____________________
`
`✔✔
`
`Credit Card Debt
`What is the nature of the claim? ____________________________
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`Unsecured claim
`
`$_____________________
`
`$_____________________
`
`Legal
`What is the nature of the claim? ____________________________
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`Unsecured claim
`
`$_____________________
`
`$_____________________
`
`✔✔✔
`✔ ✔
`
`Unsecured claim
`
`3,900.00
`$____________________________
`
`1,588.00
`$____________________________
`
`551.00
`$____________________________
`
`1.00
`$____________________________
`
`$____________________________
`1.00
`
`What is the nature of the claim? ____________________________
`Employment Dispute
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Hamish Hume, Esq. and Jessica Phillips, Esq.
`__________________________________________
`Value of security:
`Contact
`Unsecured claim
`
`____________________________________
`Contact phone
`
`Case: 20-30242 Doc# 3 Filed: 03/04/20 Entered: 03/04/20 16:37:28 Page 3 of 6
`30
`For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims
`Official Form 104
`
`page 3
`
`$_____________________
`
`$_____________________
`
`✔
`✔
`✔
`✔
`

`

`Debtor 1
`
`Anthony Scott Levandowski
`_______________________________________________________
`Last Name
`First Name
`Middle Name
`
`20-30242
`Case number (if known)_____________________________________
`
`13 __________________________________________
`
`Creditor’s Name
`
`__________________________________________
`Number
`Street
`
`__________________________________________
`
`__________________________________________
`City
`State
`ZIP Code
`
`__________________________________________
`Contact
`
`____________________________________
`Contact phone
`
`14 __________________________________________
`
`Creditor’s Name
`
`__________________________________________
`Number
`Street
`
`__________________________________________
`
`__________________________________________
`City
`State
`ZIP Code
`
`__________________________________________
`Contact
`
`____________________________________
`Contact phone
`
`15 __________________________________________
`
`Creditor’s Name
`
`__________________________________________
`Number
`Street
`
`__________________________________________
`
`__________________________________________
`City
`State
`ZIP Code
`
`__________________________________________
`Contact
`
`____________________________________
`Contact phone
`
`16 __________________________________________
`
`Creditor’s Name
`
`__________________________________________
`Number
`Street
`
`__________________________________________
`
`__________________________________________
`City
`State
`ZIP Code
`
`__________________________________________
`Contact
`
`____________________________________
`Contact phone
`
`17 __________________________________________
`
`Creditor’s Name
`
`__________________________________________
`Number
`Street
`
`__________________________________________
`
`__________________________________________
`City
`State
`ZIP Code
`
`__________________________________________
`Contact
`
`____________________________________
`Contact phone
`
`What is the nature of the claim? ____________________________
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`Unsecured claim
`
`$_____________________
`
`$_____________________
`
`What is the nature of the claim? ____________________________
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`Unsecured claim
`
`$_____________________
`
`$_____________________
`
`What is the nature of the claim? ____________________________
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`Unsecured claim
`
`$_____________________
`
`$_____________________
`
`What is the nature of the claim? ____________________________
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`Unsecured claim
`
`$_____________________
`
`$_____________________
`
`What is the nature of the claim? ____________________________
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`
`$_____________________
`
`Unsecured claim
`
`$_____________________
`
`Unsecured claim
`
`$____________________________
`
`$____________________________
`
`$____________________________
`
`$____________________________
`
`$____________________________
`
`Case: 20-30242 Doc# 3 Filed: 03/04/20 Entered: 03/04/20 16:37:28 Page 4 of 6
`31
`For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims
`Official Form 104
`
`page 4
`
`

`

`Debtor 1
`
`Anthony Scott Levandowski
`_______________________________________________________
`Last Name
`First Name
`Middle Name
`
`20-30242
`Case number (if known)_____________________________________
`
`__________________________________________
`Creditor’s Name
`
`__________________________________________
`Number
`Street
`
`__________________________________________
`
`__________________________________________
`City
`State
`ZIP Code
`
`__________________________________________
`Contact
`
`____________________________________
`Contact phone
`
`__________________________________________
`Creditor’s Name
`
`__________________________________________
`Number
`Street
`
`__________________________________________
`
`__________________________________________
`City
`State
`ZIP Code
`
`__________________________________________
`Contact
`
`____________________________________
`Contact phone
`
`18
`
`19
`
`20
`
`__________________________________________
`Creditor’s Name
`
`__________________________________________
`Number
`Street
`
`__________________________________________
`
`__________________________________________
`City
`State
`ZIP Code
`
`__________________________________________
`Contact
`
`____________________________________
`Contact phone
`
`What is the nature of the claim? ____________________________
`
`$____________________________
`
`Unsecured claim
`
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`Unsecured claim
`
`$_____________________
`
`$_____________________
`
`What is the nature of the claim? ____________________________
`
`$____________________________
`
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`Unsecured claim
`
`$_____________________
`
`$_____________________
`
`What is the nature of the claim? ____________________________
`
`$____________________________
`
`As of the date you file, the claim is: Check all that apply.
` Contingent
` Unliquidated
` Disputed
` None of the above apply
`
`Does the creditor have a lien on your property?
` No
` Yes. Total claim (secured and unsecured):
`- $_____________________
`Value of security:
`Unsecured claim
`
`$_____________________
`
`$_____________________
`
`Case: 20-30242 Doc# 3 Filed: 03/04/20 Entered: 03/04/20 16:37:28 Page 5 of 6
`32
`For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims
`Official Form 104
`
`page 5
`
`

`

`Debtor 1
`
`Anthony Scott Levandowski
`_______________________________________________________
`Last Name
`First Name
`Middle Name
`
`20-30242
`Case number (if known)_____________________________________
`
`Pa rt 2 :
`
`Sign Be low
`
`Under penalty of perjury, I declare that the information provided in this form is true and correct.
`
`______________________________________________
`
`/s/ Anthony Scott Levandowski
`Signature of Debtor 1
`
`______________________________________________
`
`Signature of Debtor 2
`
`03/04/2020
`Date _________________
`MM / DD
`/ YYYY
`
`
`Date
`MM / DD / YYYY
`
`Case: 20-30242 Doc# 3 Filed: 03/04/20 Entered: 03/04/20 16:37:28 Page 6 of 6
`For Individual Chapter 11 Cases: List of Creditors Who Have the 20 Largest Unsecured Claims
`Official Form 104
`
`page 6
`
`