UNITED STATES BANKRUPTCY COURTAFFIDAVIT FOR REIMBURSEMENTNORTHERN DISTRICT OF ALABAMAOF UNCLAIMED FUNDS BYCORPORATION AND/OR COMPANY******************************************************************************************** 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 the herein below company and/or corporation in the sum of $ . Affiant avers that his/her name is , and that he/she is the of , and that he/she is the (officer or agent) (name of company or corporation)duly authorized Petitioner to make this affidavit. Affiant avers that , is one and the same as described (Name of company or corporation) in the matter of , in the Bankruptcy case number as a . That said creditor duly filed his/her claim, (Case Number) (Creditor or other party)which was thereafter duly allowed. That said claim has not been sold or assigned, and that it is still the property of the deponent and these monies remain unpaid. It is therefore requested that the Clerk of this Court pay to the sum of $ . Tax ID No. or Social Security No. (Signature of Affiant) (Name of company and/or Corporation) (Address of company and/or corporation) (City and state and zip code)Sworn to and subscribed to before me on this day of ,20 . Notary Public(Affix Seal) American LegalNet, Inc. www.FormsWorkFlow.com