Declaration CCP 585Cal. Super. - 6th Dist.March 29, 2021mmbwmw \J 10 11 12 13 14 15 l6 17 18 19 20 21 22 23 24 25 26 27 28 21CV381415 Santa Clara - Civil 7] l2 Ry UOUJ&WW LAW OFFICES 0F KENNETH J. FREED E'ecmn'f‘a'w Wed KENNETH J. FREED, ESQ. [State Bar No. 125349] by Superlor Court 0f CA, DAVID E. WEEKS. ESQ. [State Bar No. 125349] County of Santa Clara, 14226 Ventura Boulevard on 7/22/2021 11:20 AM Sherman Oaks, California 91423 Reviewed B . D Harris(313) 990-0833; (s13) 990-1047 Fax y' KEREED@K1FE§Q.gQM/DW5§KS@KJFE§Q,gQfiaSG #21 CV331 41 5 Envelope: 6903178 Attorneys for Plaintiff CREDITORS ADJUSTMENT BUREAU, INC. Our File No. 6062496 SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA SANTA CLARA COURTHOUSE, UNLIMITED CIVIL CREDITORS ADJUSTMENT BUREAU, CASE NO. 21CV38 1415 DECLARATION pURSUANT To c.c.P. SECTION 535(d) AND ASSIGNMENT Plaintiff, DRY, INC DBA PEGASUS REFINISHING.; and DOES 1 through 10, Inclusive, [Electronic Signature Per C.R.C. ) ) ) ) i CAMPBELL DRY INC. AKA CAMPBELL g ) 3 2.257] )Defendant. I, Melissa Klopstock, do hereby declare as follows: 1. That I am a Collections Representative ofSTATE COMPENSATION INSURANCE FUND, plaintiffs assignor in the action herein pending. I am personally familiar with the following facts and if called to the stand to testify, I could and would competently testify with personal knowledge thereto; 2. That the documents and records attached hereto were taken from the files 0f STATE COMPENSATION INSURANCE FUND and were prepared in the ordinary course of business about the time that the occurrences cited therein actually took place by employees and/or agents 0f STATE COMPENSATION INSURANCE FUND having personal knowledge of the .mwMH \Dm-dmm 11 12 13 14 15 l6 l7 18 19 20 21 22 23 24 25 26 27 28 occurrences which are cited in said documents. 3. As a Collections Representative ofSTATE COMPENSATION INSURANCE FUND, I have personal knowledge regarding all issues relating to the accounting system and record keeping ofSTATE COMPENSATION INSURANCE FUND, including issues relating, but not limited to, price quoting, invoicing, delivery, and applying payments to, and collection of, customer accounts. As part ofmy duties as the Collections Representative, Imaintain custody and control of the files with respect to the account pertaining to defendant. 4. That Plaintiff's Assignor issued a policy 0f workers compensation insurance, Policy No. 921 9123-17 (covering the period of October 4, 2017 through October 4, 201 8) to Defendant at Defendant's instance and request. Defendant became indebted to Plaintiffs Assignor in the sum of$49,907.97 for insurance prémiums earned pursuant to the terms and conditions of the policy. A true and correct copy of each outstanding invoice accurately reflects the obligation owed by defendant at the time the account was assigned to Creditors Adjustment Bureau, Inc. is attached hereto and marked as Exhibit “1" and incorporated heroin by this reference as though fully set forth. Ihave reviewed the invoice and it correctly reflects the status of defendant’s account. 5. All amounts indiCEncd 0n the invoices, including, but not limited t0, the user assessment fimd and fraud assessment fund, are mandated by the Insurance Commissioner of the State of California. 6. That I am authorized by STATE COMPENSATION INSURANCE FUND to assign the above-referenced account for collection in the sum of $49,907.97 and thereby assigned the account to CREDITORS ADJUSTMENT BUREAU, INC. for collection with full right to file legal action in the name of CREDITORS ADJUSTMENT BUREAU, INC. ll {I l/ I/ l/ II meH 4mm 10 11 12 13 14 15 16 1'? l8 19 20 21 22 23 24 25 26 27 28 7. Although demand has been made upon defendant for payment of same, defendant has failed and fefiJsed to pay any sum towards the balance. It is therefore respectfully requested that judgment be entered in favor of plaintiff and against defendant in the sum of $49,907.97 principal, cost of suit, interest at 10% per annum from the dates of default in the complaint, plus attorney fees pursuant to California Civil Code Section 1717.5. I declare under penalty of perjury that the foregoing is true and correct. Executed on this 12 day of July, 2021, at Fairfield , California. 2mmKW Melissa Klopstock Declarant F#6062496 bumb- wflmm 10 11 12 13 14 15 15 17 18 19 20 21 22 23 24 25 26 27 28 EXHIBIT “1" AMOUNT DUE 349,90? . 97 DUE DATE ki'uNU-quqgmigflgggo } .. - .- u. 1. 05’04/20 5‘ .Lhfigd'.q..uel.ir'_ . .. . .I .;_ STATE kf CnMI‘rHGA‘ncIN : IH SURAHCI?FUND 10000992191231702000040?20320000000004990797116P.O.Box7441 SAN FRANCISCO. CA 94120-74“ 04/07/20 3 h 2 CAMPBELL DRY INC. onoup U Foucwumr 9219123 ' 17 2 2784 HOMESTEAD RD. ST. SUITE 264 [:1 SN'I‘A CLARA, CA 95051 NA N 8r BECK 80X AT LEFJ' FOR fiDDHESS CHANGE ADDRESS CITY. STATE ZIP fi‘“\ 3.4-..- PAY ONLINE at www.slatefunclca.com or detach here and include this remittance slut) with your payment. YOUR FINAL AUDIT STATEMENT - 2017 I CAMPBELL DR: Inc. POLICY as 9219123-17 IHCBPTIOH nnwn: 10/04/2017 2181 Hongswnan an. 3T. SUITE 26; sxvtnnwzou nuts: 10/01/2018 aura onnnn, ca 95051 souncs: AUDIT 10/04/201?-1o/04;2018 pnraonn vavnonn ans: cnass conzs nsponwxn aunxrnn x ans: nave / 1uo - pneu1uu 8810-1 CLERICAL OFFICE EMPLOYEES .00 56,160.00 x 0.74 I 100 - 415.53 9501-1 PAINTING-saor ONLY 150,239.50 529,582.24 x 10.55 I loo - 66,a31.a8 SUBTOTAL BASE rnznxun 65,347.06 RATING PLAN HoanIER x 1.33000 SUBTOTAL HonIFIBD PREMIUM 92,243.94 PREHIUH DISCOUNT KODIFIER X 0.89312 TorAL vnuurun Fox POLICY #9219123-17 32,389.37 MANDATORY INSURANCE suncaanszs CIGA @2.ooooux x 32,959.04 659.13 "ca @o.3lzsoz x 52,339.37 257.?1 HCFA @0.16750z x 32,339.37 138.00 DEBT @0.0721oz x 32.339.3? 59.40 515T @0.13350:¢ x 82,389.37 109.99 osnr @0.23050: x 32,339.37 139.91 Lac €0.19laox x 32,339.37 153.02 TOTAL suncaAncEs 1,512.21 55“??? P.o. Box 7m FUND SAN FRANCisco. CA 94120-7441 6222 mew ma: PAY ONLINE a1 www.slateiundca.corn PAGE 001 OP 002 Thank yau Ior your business. Questions? Payhrphone? Address Charm“- caw SBE-SWEFUND {836-732-8338} See raveraa tor paymeni instructions 'I ' STATE AMOUNI DUE DUE DATE mamfienggqsgufl __ . a: '1‘." fi- l-uW5 .I' J $49,907.97 osxnaxzo g i I=LJPJE3 Rofioxn“ ° 100009921912317a2000040720320000000004990797116 3AM FHMCISCO. CA 94120-7441 U 4ID 7/2 0 3 A 2 CAMPBELL DRY INC . GROUP D pq‘cwumr 92191.23 "' 17 2 2784 HOMESTEAD RD. 5T. SUITE 264 D SNTA CLARA, CA 95051 NR N S: 5'" j CHECK BOX AT LEFT FOBADDRESSCHM - . - ADDRESS CITY. STATE ZIP PAY ONLINE a1 www.Stalclundca.{:orn or detach here and include 1his remittance stub wilh your payment. YOUR FINAL AUDIT STATEMENT ~ 2017 CAMPBELL DRY INC. POLICY fil 9219123-17 INCEPTION DATE: 10/01/2017 2784 HOMESTEAD RD. 8T. SUITE 26‘ ERPIRATION DATE: lD/Oi/ZOIB SNTA CLARA, Ch 95051 SOURCE: AUDIT TOTAL CHARGES 83,961.58 PAXHENTS fl CREDITS PREMIUH PaIn 32,959.0acn EUROBARGBS PAID 1.094.5ECR TOTAL - PAYHBNTS & CREDITS 3&,053.62£R ' BALANCE DUE PAY BY 05/04/2020 $49,907.97 han f . ?TfiT? 9.0.80): 7m T kyou or your business .ngu. Ago" 5m FEMISCOI CA 94‘2““, pm ONLINE a: www.statafundca.com Questions? Paybypnune? Address Change?N . Can esavsmasuno (383-762-3333) mawemds, PAGE 002 OF 002 LP SeerevarceforpayrnantInstructions
