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UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF ALABAMA AFFIDAVIT FOR REIMBURSEMENT OF UNCLAIMED FUNDS BY INDIVIDUAL ************************************************************************************************************** SW ORN PETITION FOR PAYM ENT OF FUNDS HELD IN THE REGISTRY OF THE COURT, TITLE 28, U. S. C. S., §2042, W ITHDRAW AL T h e u n d e rs ig n e d file s th is p e titio n u n d e r o a th fo r th e p u rp o se o f in d u cin g th e p a ym e n t o f th e su m of $ . P e titio n e r a v e rs th a t h is /h e r n a m e is , c ity o f , S ta te /Z ip , a n d re sid e s a t P e titio n e r is o v e r th e a g e o f 2 1 y e a rs a n d is o n e a n d th e sa m e p e rso n a s th e p e rso n d e scrib e d in th e m a tte r o f ,a s a (Case Number) (Creditor or other party) , in th e B a n kru p tcy C a se N u m b e r , a n d is e n title d to th e d ivid e n d o r o th e r m o n ie s a w a rd e d h im /h e r in th e sa id c a s e . P e titio n e r sta te s th a t h e /sh e d u ly file d th e ir cla im w h ich w a s th e re a fte r d u ly a llo w e d . T h a t th e s a id cla im h a s n o t b e e n so ld o r a ssig n e d a n d is still th e p ro p e rty o f d e p o n e n t. It is th e re fo re re q u e ste d th a t th e C le rk o f th is C o u rt p a y to (Name of Claimant) th e s u m o f $ . S o c ia l S e c u rity N o . (S ig n a tu re o f C la im a n t) S w o rn to a n d s u b s c rib e d to b e fo re m e th e day of , 20 . N o ta ry P u b lic (Affix Seal) American LegalNet, Inc. www.FormsWorkFlow.com
