United States Bankruptcy Court, Southern District of Texas

Modified Official Form 410

Proof of Claim for SmileDirectClub, Inc. Chapter 11 cases 04/22

Read the instructions at the end before filling out this form. This form is for making a claim for payment in a bankruptcy case. Do not use this
form to make a request for payment of an administrative expense (other than a claim entitled to priority under 11 U.S.C. § 503(b)(9)). Make such
a request according to 11 U.S.C. § 503.
Your filled-out form may be visible on a public website. Leave out or redact (black out) 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.
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.

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.

Fill in this information to identify the case

(Select only one Debtor per claim form):
SmileDirectClub, Inc. SDC Plane, LLC
(Case No. 23-90786) (Case No. 23-90791)
SmileDirectClub, LLC SmileFarm, LLC
(Case No. 23-90784) (Case No. 23-90792)
Ortho Lab Services, LLC
(Case No. 23-90785)
Access Dental Lab, LLC
(Case No. 23-90787)
CAMF II, LLC
(Case No. 23-90788)
SDC Financial LLC
(Case No. 23-90789)
SDC Holding, LLC
(Case No. 23-90790)

Part 1: Identify the Claim

1. Who is the current

creditor?
Name of the current creditor (the person or entity to be paid for this claim)

Other names the creditor used with the debtor

2. Has this claim been

acquired from
 No
someone else?  Yes. From whom?

3. Where should notices Where should notices to the creditor be sent? Where should payments to the creditor be sent? (if
and payments to the different)
creditor be sent?
Federal Rule of _____________________________________________________ _____________________________________________________
Bankruptcy Procedure Name Name
(FRBP) 2002(g)
______________________________________________________ ______________________________________________________
Number Street Number Street

______________________________________________________ ______________________________________________________
City State ZIP Code City State ZIP Code

Contact phone Contact phone

Contact email Contact email

4. Does this claim amend  No

one already filed?  Yes. Claim number on court claims registry (if known) Filed on
MM / DD / YYYY

5. Do you know if anyone  No

else has filed a proof  Yes. Who made the earlier filing?
of claim for this claim?

Proof of Claim page 1

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

6. Do you have any number  No

you use to identify the  Yes. Last 4 digits of the debtor’s account or any number you use to identify the debtor:
debtor?

7. How much is the claim? $ . Does this amount include interest or other charges?
 No
 Yes. Attach statement itemizing interest, fees, expenses, or other
charges required by Bankruptcy Rule 3001(c)(2)(A).

8. What is the basis of the Examples: Goods sold, money loaned, lease, services performed, personal injury or wrongful death, or credit card.
claim?
Attach redacted copies of any documents supporting the claim required by Bankruptcy Rule 3001(c).
Limit disclosing information that is entitled to privacy, such as health care information.

9. Is all or part of the claim  No

secured?  Yes. The claim is secured by a lien on property.
Nature of property:
 Real estate. If the claim is secured by the debtor’s principal residence, file a Mortgage Proof of Claim
Attachment (Official Form 410-A) with this Proof of Claim.
 Motor vehicle
 Other. Describe:

Basis for perfection:

Attach redacted copies of documents, if any, that show evidence of perfection of a security interest (for
example, a mortgage, lien, certificate of title, financing statement, or other document that shows the lien has
been filed or recorded.)

Value of property: $

Amount of the claim that is secured: $

Amount of the claim that is unsecured: $ (The sum of the secured and unsecured
amounts should match the amount in line 7.)

Amount necessary to cure any default as of the date of the petition: $

Annual Interest Rate (when case was filed) %

 Fixed
 Variable

10. Is this claim based on a  No

lease?
 Yes. Amount necessary to cure any default as of the date of the petition. $

11. Is this claim subject to a  No

right of setoff?
 Yes. Identify the property:

Modified Official Form 410 Proof of Claim page 2

12. Is all or part of the claim  No
entitled to priority under
11 U.S.C. § 507(a)?  Yes. Check one: Amount entitled to priority

A claim may be partly  Domestic support obligations (including alimony and child support) under
priority and partly 11 U.S.C. § 507(a)(1)(A) or (a)(1)(B). $
nonpriority. For example,
in some categories, the  Up to $3,350* of deposits toward purchase, lease, or rental of property or services for
law limits the amount personal, family, or household use. 11 U.S.C. § 507(a)(7). $
entitled to priority.
 Wages, salaries, or commissions (up to $15,150*) earned within 180 days before the
bankruptcy petition is filed or the debtor’s business ends, whichever is earlier. $
11 U.S.C. § 507(a)(4).
 Taxes or penalties owed to governmental units. 11 U.S.C. § 507(a)(8). $

 Contributions to an employee benefit plan. 11 U.S.C. § 507(a)(5). $

 Other. Specify subsection of 11 U.S.C. § 507(a)( ) that applies. $

* Amounts are subject to adjustment on 4/01/25 and every 3 years after that for cases begun on or after the date of adjustment.

13. Is all or part of the  No

claim entitled to
administrative priority  Yes. Indicate the amount of your claim arising from the value of any goods received $ ____________________
pursuant to by the Debtor within 20 days before the date of commencement of the above case, in
11 U.S.C. § 503(b)(9)? which the goods have been sold to the Debtor in the ordinary course of such
Debtor’s business. Attach documentation supporting such claim.

Part 3: Sign Below

The person completing Check the appropriate box:

this proof of claim must
sign and date it.  I am the creditor.
FRBP 9011(b).  I am the creditor’s attorney or authorized agent.
If you file this claim  I am the trustee, or the debtor, or their authorized agent. Bankruptcy Rule 3004.
electronically, FRBP  I am a guarantor, surety, endorser, or other codebtor. Bankruptcy Rule 3005.
5005(a)(2) authorizes courts
to establish local rules I understand that an authorized signature on this Proof of Claim serves as an acknowledgment that when calculating the
specifying what a signature amount of the claim, the creditor gave the debtor credit for any payments received toward the debt.
is.
I have examined the information in this Proof of Claim and have a reasonable belief that the information is true
A person who files a and correct.
fraudulent claim could be
fined up to $500,000, I declare under penalty of perjury that the foregoing is true and correct.
imprisoned for up to 5
years, or both. Executed on date (mm/dd/yyyy)
18 U.S.C. §§ 152, 157, and
3571.

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

Name
First name Middle name Last name

Title

Company
Identify the corporate servicer as the company if the authorized agent is a servicer.

Address
Number Street

City State ZIP Code

Contact phone Email

Modified Official Form 410 Proof of Claim page 3

 Instructions for Proof of Claim
United States Bankruptcy Court 12/15

These instructions and definitions generally explain the law. In certain circumstances, such as bankruptcy cases that debtors do
not file voluntarily, exceptions to these general rules may apply. You should consider obtaining the advice of an attorney,
especially if you are unfamiliar with the bankruptcy process and privacy regulations.

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.

How to fill out this form

 For a minor child, fill in only the child’s initials and
 Fill in all of the information about the claim as of the the full name and address of the child’s parent or
date the case was filed. guardian. For example, write A.B., a minor child (John
Doe, parent, 123 Main St., City, State). See Bankruptcy
Rule 9037.
 Fill in the caption at the top of the form.

 If the claim has been acquired from someone else,

then state the identity of the last party who owned the
Confirmation that the claim has been filed
claim or was the holder of the claim and who transferred it
to you before the initial claim was filed. To receive confirmation that the claim has been filed, either
enclose a stamped self-addressed envelope and a copy of this
form. You may view a list of filed claims in this case by
 Attach any supporting documents to this form. visiting the Claims and Noticing Agent's website at
Attach redacted copies of any documents that show that the https://restructuring.ra.kroll.com/smiledirectclub.
debt exists, a lien secures the debt, or both. (See the
definition of redaction on the next page.)
Understand the terms used in this form
Also attach redacted copies of any documents that show
Administrative expense: Generally, an expense that arises
perfection of any security interest or any assignments or
after a bankruptcy case is filed in connection with operating,
transfers of the debt. In addition to the documents, a
liquidating, or distributing the bankruptcy estate.
summary may be added. Federal Rule of Bankruptcy
11 U.S.C. § 503.
Procedure (called “Bankruptcy Rule”) 3001(c) and (d).
Claim: A creditor’s right to receive payment for a debt that the
 Do not attach original documents because debtor owed on the date the debtor filed for bankruptcy. 11
attachments may be destroyed after scanning. U.S.C. §101 (5). A claim may be secured or unsecured.

Claim Pursuant to 11 U.S.C. § 503(b)(9): A claim arising from

 If the claim is based on delivering health care goods
the value of any goods received by the Debtor within 20 days
or services, do not disclose confidential health care
before the date of commencement of the above case, in which
information. Leave out or redact confidential
the goods have been sold to the Debtor in the ordinary course of
information both in the claim and in the attached
documents.
the Debtor's business. Attach documentation supporting such
claim.
 A Proof of Claim form and any attached documents
must show only the last 4 digits of any social security
number, individual’s tax identification number, or
financial account number, and only the year of any
person’s date of birth. See Bankruptcy Rule 9037.
Creditor: A person, corporation, or other entity to whom a Setoff: Occurs when a creditor pays itself with money
debtor owes a debt that was incurred on or before the date the belonging to the debtor that it is holding, or by canceling a debt
debtor filed for bankruptcy. 11 U.S.C. § 101 (10). it owes to the debtor.

Debtor: A person, corporation, or other entity who is in Unsecured claim: A claim that does not meet the requirements
bankruptcy. Use the debtor’s name and case number as shown of a secured claim. A claim may be unsecured in part to the
in the bankruptcy notice you received. 11 U.S.C. § 101 (13). extent that the amount of the claim is more than the value of the
property on which a creditor has a lien.
Evidence of perfection: Evidence of perfection of a security
interest may include documents showing that a security interest Offers to purchase a claim
has been filed or recorded, such as a mortgage, lien, certificate
Certain entities purchase claims for an amount that is less than
of title, or financing statement.
the face value of the claims. These entities may contact
Information that is entitled to privacy: A Proof of Claim form
creditors offering to purchase their claims. Some written
and any attached documents must show only the last 4 digits of communications from these entities may easily be confused
any social security number, an individual’s tax identification with official court documentation or communications from the
number, or a financial account number, only the initials of a debtor. These entities do not represent the bankruptcy court, the
minor’s name, and only the year of any person’s date of birth. If bankruptcy trustee, or the debtor. A creditor has no obligation
a claim is based on delivering health care goods or services, to sell its claim. However, if a creditor decides to sell its claim,
limit the disclosure of the goods or services to avoid any transfer of that claim is subject to Bankruptcy Rule
embarrassment or disclosure of confidential health care 3001(e), any provisions of the Bankruptcy Code (11 U.S.C. §
information. You may later be required to give more 101 et seq.) that apply, and any orders of the bankruptcy court
information if the trustee or someone else in interest objects to that apply.
the claim. Please send completed Proof(s) of Claim to:
Priority claim: A claim within a category of unsecured claims If by first class mail:
that is entitled to priority under 11 U.S.C. § 507(a). These SmileDirectClub, Inc. Claims Processing Center
claims are paid from the available money or property in a c/o Kroll Restructuring Administration LLC
bankruptcy case before other unsecured claims are paid. Grand Central Station, PO Box 4850
Common priority unsecured claims include alimony, child New York, NY 10163-4850
support, taxes, and certain unpaid wages.

Proof of claim: A form that shows the amount of debt the If by overnight courier or hand delivery:
debtor owed to a creditor on the date of the bankruptcy filing. SmileDirectClub, Inc. Claims Processing Center
The form must be filed in the district where the case is pending. c/o Kroll Restructuring Administration LLC
850 Third Avenue, Suite 412
Redaction of information: Masking, editing out, or deleting Brooklyn, NY 11232
certain information to protect privacy. Filers must redact or
leave out information entitled to privacy on the Proof of Claim
form and any attached documents. You may also file your claim electronically at
https://restructuring.ra.kroll.com/smiledirectclub/EPOC-Index.
Secured claim under 11 U.S.C. § 506(a): A claim backed by
a lien on particular property of the debtor. A claim is secured
to the extent that a creditor has the right to be paid from the Do not file these instructions with your form
property before other creditors are paid. The amount of a
secured claim usually cannot be more than the value of the
particular property on which the creditor has a lien. Any
amount owed to a creditor that is more than the value of the
property normally may be an unsecured claim. But exceptions
exist; for example, see 11 U.S.C. § 1322(b) and the final
sentence of § 1325(a).
Examples of liens on property include a mortgage on real
estate or a security interest in a car. A lien may be voluntarily
granted by a debtor or may be obtained through a court
proceeding. In some states, a court judgment may be a lien.