Complete this questionnaire if you have received a notice from the Bankruptcy Administrator that you are eligible to serve on an Official Unsecured Creditors Committee. Collection of this information is authorized by 11 U.S.C. Section 1102. This information will be used solely for the purpose of determining whether a creditor may be eligible to serve on an Official Unsecured Creditors Committee. Certain information including contact name, mailing address and phone number may be disclosed in court filings necessary for the creation of the Committee. Disclosure of other information may be made to a trustee or examiner as necessary for the performance of their duties or in accord with applicable law.