UNITED STATES BANKRUPTCY COURT EASTERN AND WESTERN DISTRICTS OF ARKANSAS Procedures for Withdrawal of Unclaimed Funds Applications for payment of unclaimed funds will only be processed when filed by either the owner of the funds, the owner’s duly authorized agent or representative, or successor in interest to the original owner. Upon receipt of the application (see next page for PDF application), the financial department will review the application and supporting documentation for accuracy and validity, verify that the requested funds remain on deposit with the Court, and forward the application and supporting documentation to the appropriate Bankruptcy Judge for final disposition. All checks issued as a result of an application submitted by an attorney or “funds locator” who has been retained by the owner or successor in interest to the original owner shall be made payable to the owner or successor in interest to the original owner and mailed in care of the applicant. Questions concerning these procedures should be directed to the Financial Department, U. S. Bankruptcy Court, 300 W. 2nd St., Little Rock, Arkansas 72201, (501) 918-5512 or (501) 918-5510. American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES BANKRUPTCY COURT EASTERN AND WESTERN DISTRICTS OF ARKANSAS In re: ____________________________ Case No. _____________________ APPLICATION FOR UNCLAIMED FUNDS I, the undersigned, 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 applying to receive $_________________, the total of all money deposited with the court by the trustee, on behalf of the debtor or creditor whose name is _________________________and whose SSN/Tax ID# is___________________. 2. Please check and complete only the ONE applicable subparagraph below. A. I am the creditor/debtor named in paragraph 1; and if not an individual, my title is (e.g., owner, partner, etc.) ______________________________________________________________________________________. B. I am an employee of the creditor/debtor named in paragraph 1 and my title is _______________________________. The creditor/debtor is still legally entitled to the money and I am authorized by such creditor/debtor to file this petition. C. I am the lawful attorney-in-fact for the creditor/debtor named in paragraph 1 and I am duly authorized by the attached original notarized power of attorney to file this petition. I am aware of all pertinent state law requirements regarding powers of attorney. The following is the address, phone number, and a brief history of the creditor/debtor named in paragraph 1 (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). Attach additional sheet(s) if necessary. _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________________________________________________________. D. Subparagraphs A, B & C above do not apply, but I am entitled to payment of such money because [state basis for your claim and provide certified copies of supportive documents (e.g., proof of the transfer of assets of the business originally entitled to the funds, sale of the company, probate documents to substantiate the right to act on behalf of the descendants estate, etc.)]___________________________________________________ _______________________________________________________________________________________ _________________________________________________________________________________________. 3. I have no knowledge that any other party may be entitled to these funds and am not aware of any dispute regarding these funds. 4. Enclosed is a photocopy of photo identification (e.g., driver's license or passport) of the applicant named below. 5. I understand that, pursuant to 18 U.S.C. §152, I will 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. 6. On ______________ I mailed BOTH: (a) the ORIGINAL of this document (fully completed) to the office of the Clerk, U.S. Bankruptcy Court, 300 W. Second St., Little Rock AR 72201; AND (b) a COPY to the U.S. Attorney at P. O. Box 1524, Fort Smith, AR 72902 (Western District) or P. O. Box 1229, Little Rock, AR 72203 (Eastern District), per 28 U.S.C. §2042 ___________________________________________ Applicant's Signature (Bar# if attorney) ___________________________________________ Applicant's Name (Type or Print) ___________________________________________ Date _____________________________________________ Applicant’s Telephone Number _____________________________________________ Applicant’s Street Address _____________________________________________ City, State and Zip American LegalNet, Inc. www.FormsWorkFlow.com