UNITED STATES BANKRUPTCY COURT FOR THE SOUTHERN DISTRICT OF IOWA 110 E. Court Avenue, Ste 300 Des Moines, Iowa 50309 www.iasb.uscourts.gov In the Matter of: Case No. MOTION FOR PAYMENT OF UNCLAIMED FUNDS Now comes (movant's name, address, telephone number:) represented by _________________________, hereby requests that the court enter an Order for Payment of Unclaimed Funds, and in support of the motion, states: A check in the amount of $______________ belonging to (name of original creditor/claimant)_______________________________________________ was tendered to the Clerk of Bankruptcy Court by the case trustee as unclaimed funds. The amount stated is being held in the Treasury of the United States as unclaimed funds. Movant is entitled to receive the requested funds based upon (check all that apply): Movant is the owner of said funds being the owner appearing on the records of this Court. Movant is the assignee of the owner of the claim to said funds, as evidenced in the attached Affidavit or Assignment or Right. other identifying documents. Movant is the owner's successor in interest, as evidenced in the attached Affidavit and/or Movant is the personal representative of the owner's estate, as evidenced in the attached Affidavit and/or other identifying documents. J:\Web\Forms\PDF Files\Mo Unclaimed Funds.pdf 7/19/13 American LegalNet, Inc. www.FormsWorkFlow.com  Movant's representative is named in a LIMITED POWER OF ATTORNEY by movant/grantor ___________________________________________, as evidenced in the attached Power of Attorney document that empowers the movant's representative to collect the unclaimed funds described above on behalf of the movant/grantor: As the owner of the claim. As the owner's attorney at law, with authorization to receive said funds. As the assignee of the owner's claim to said funds. As the owner's successor in interest. As the personal representative of the owners estate. The following documents are submitted, as proof of the movant's/grantor's identity and status as the owner of claim of entitlement: Power of Attorney Formal Assignment Letter of Appointment Court Order Other (describe) _________________________________________________ WHEREFORE, movant/movant's representative requests the Court to enter an Order Directing Payment of the Unclaimed Funds described above to ___________________________, at the following address in accordance with the documents submitted in support of this motion. The movant/movant's representative declares under penalty of perjury, under the laws of the United States of America, that the foregoing is true and correct. The movant/movant's representative understands that they may be subject to a fine or imprisonment, or both, if they have knowingly and fraudulently made any false statements in this document. Date: Signature Name Title Address __________________________ __________________________ __________________________ __________________________ __________________________ SUBSCRIBED AND SWORN before me this ____ day of __________________, 20___. Signature: __________________________ NOTARY PUBLIC in and for the State of _______________________, Residing in ___________________ County. My commission expires: _______________ J:\Web\Forms\PDF Files\Mo Unclaimed Funds.pdf 7/19/13 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF SERVICE I, ___________________________, certify that the Motion for Payment of Unclaimed Funds was either electronically served or served via the U.S. Post Office on the __________ day of __________________, 20____, upon the following parties: (List name and address of all parties served. Service must include the following: U.S. Attorney for the Southern District of Iowa 110 E Court Avenue Room 286 US Courthouse Annex Des Moines, IA 50309 U.S. Trustee for the Southern District of Iowa Federal Building, Room 793 210 Walnut Street Des Moines, IA 50309 Case Trustee __________________________________________ __________________________________________ __________________________________________ __________________________________________ Debtor __________________________________________ __________________________________________ __________________________________________ __________________________________________ Debtor's Attorney __________________________________________ __________________________________________ __________________________________________ __________________________________________ Any other party to this motion) __________________________________________ __________________________________________ __________________________________________ __________________________________________ Signature ___________________________ Name ___________________________ Address ___________________________ Telephone ___________________________ J:\Web\Forms\PDF Files\Mo Unclaimed Funds.pdf 7/19/13 American LegalNet, Inc. www.FormsWorkFlow.com