American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES BANKRUPTCY COURTAFFIDAVIT FOR REIMBURSEMENTNORTHERN DISTRICT OF ALABAMA OF UNCLAIMED FUNDS BY INDIVIDUAL(S)************************************************************************************************************** SWORN PETITION FOR PAYMENT OF FUNDS HELD IN THE REGISTRY OF THE COURT, TITLE 28, U. S. C. S., 2472042, WITHDRAWALThe undersigned files this petition under oath for the purpose of inducing the payment to them of the sum of $ . Petitioner(s) aver that their names are , and that they reside at , city of , State of .Petitioner(s) are over the age of 21 years and are one and the same persons as the persons described in the matter of , in the Bankruptcy Case Number ,as a , and is entitled to the dividend or (Case No.) (Creditors or other parties)other monies awarded them in the said case. Petitioner(s) state that they duly filed their claim whichwas thereafter duly allowed. That the said claim has not been sold or assigned and is still theproperty of deponent. It is therefore requested that the Clerk of this Court pay to (Names of Claimants) the sum of $ . Social Security No. (Signature of Claimant) Social Security No. (Signature of Claimant)Sworn to and subscribed to before me the day of , 20 . Notary Public(Affix Seal)