UNITED STATE BANKRUPTCY COURT EASTERN DISTRICT OF MICHIGAN In re: Case No. ______________________ Chapter AFFIDAVIT OF CLAIMANT I, ________________________________________________, do hereby state that I am the claimant to the unclaimed funds released in this application and that I am, to the best of my knowledge, the legal owner of these funds. Mailing address: ____________________________________ Phone number: Social security number XXX-XXIf claimant is a corporation, the federal tax ID number 1. Claimant History: Substantiate claimant’s right to the claim; i.e. if the payment is to an individual, include a copy of driver’s license or state identification card. If a corporation, include purchase agreements regarding the right to ownership. Attached are certified copies of all necessary documentation. 2. I (or the company which I represent) neither have previously received remittance for this claim nor contracted with any other party other than the person named in item one above to recover these funds. American LegalNet, Inc. www.FormsWorkflow.com Page 2 of 2 Affidavit of Claimant I declare under penalty of perjury that the foregoing copy is true and correct. Dated: __ _________ ___ Signature of Claimant Sworn to and Subscribed before me this ____ day of _________________, 20___ __________________________________ NOTARY PUBLIC AT LARGE STATE OF ________________________ American LegalNet, Inc. www.FormsWorkflow.com