U.S. Bankruptcy Court 120 N Henry St Rm 140 Madison WI 53703 UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF WISCONSIN In re: Case No. PETITION TO CLAIM UNCLAIMED FUNDS FROM U.S. TREASURY Debtor(s) I, the undersigned petitioner, under penalty of perjury under the laws of the United States of America, declare (or certify, verify or state) that the following statements and information are true and correct: 1. I am petitioning to receive the total amount of $ with the court by the case trustee on behalf of the creditor Please check and complete the applicable subparagraph below. A. B. I am the creditor named in paragraph #1. I am an employee of the creditor named in paragraph #1 and my title is . The creditor is still legally entitled to the monies and I am authorized by the creditor to file this petition. I am the lawful attorney-in-fact or the creditor named in paragraph #1 and I am duly authorized by the attached original power of attorney to file this petition. I am aware of all pertinent state law requirements regarding such powers of attorney. The following is the creditor's address and phone number, and a brief history of the creditor (from filing of the claim to present), which includes, if applicable, identification of any sale of the company and the new and prior owner(s): which is the sum of all monies deposited . 2. C. D. Subparagraphs A and B above do not apply, but I am entitled to payment of such monies because (state basis for your claim): 3. I understand that, pursuant to 18 U.S.C. § 152, I may be fined not more than $5,000, or imprisoned not more than five years, or both, if I have knowingly and fraudulently made any false statements in this document. On , a copy of this fully completed document was mailed to the U.S. Attorney, 660 West Washington Ave, Ste 303, Madison WI 53703, per 28 U.S.C. § 2042. ________________________________________________________ Petitioner's Signature Date 4. Petitioner's Name (Type or Print) Petitioner's Address Petitioner's Social Security Number or Tax Identification Number American LegalNet, Inc. www.FormsWorkFlow.com STATE OF ____________________________ COUNTY OF __________________________ On _____________________ before me personally appeared _________________________________________ Date The applicant who signed above is personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument. WITNESS my hand and official seal. (SEAL) _________________________________________________ Notary Public My Commission expires on: __________________________ American LegalNet, Inc. www.FormsWorkFlow.com