Attorney or Party Name, Address, Telephone & FAX Nos., State Bar No. & Email Address FOR COURT USE ONLY Individual appearing without attorney Attorney for: UNITED STATES BANKRUPTCY COURT CENTRAL DISTRICT OF CALIFORNIA - **SELECT DIVISION** In re: CASE NO.: DIVISION CHAPTER: SELECT CHAPTER MOTION FOR ORDER RELEASING UNCLAIMED FUNDS Debtor(s). I, under penalty of perjury under the laws of the United States declare (or certify, verify, or state) that the following statements and information are true and correct: 1. I request an order releasing the total amount of $ with the court on the following date(s) behalf of the creditor on claim number(s) 2. Please check and complete the applicable subparagraph(s) 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 this petition. Submit evidence establishing authority to act on behalf of creditor. I am the creditor and have appointed as my lawful attorney-in-fact who is duly authorized by the attached original power of attorney to file this motion. which is the sum of all monies deposited on . c. This form is optional. It has been approved for use in the United States Bankruptcy Court for the Central District of California. December 2012 Page 1 F 3011-1.MOTION.UNCLAIMED.FUNDS d. Subparagraphs a, b, and c above do not apply, but I am entitled to payment of such monies because (submit evidence establishing basis for right to obtain payment): 3. Please complete each of the following subparagraphs: a. The following is the creditor's address and phone number: b. A brief history of the creditor (from the filing of the claim to the present) which includes, if applicable, identification of any sale of the company and the new and prior owner(s). Submit evidence establishing the sale of the company from the prior to the new owner(s): 4. I understand that, pursuant to 18 U.S.C. § 152, I may be fined or imprisoned, or both, if I have knowingly and fraudulently made any false statements in this document. This form is optional. It has been approved for use in the United States Bankruptcy Court for the Central District of California. December 2012 Page 2 F 3011-1.MOTION.UNCLAIMED.FUNDS (Corporate seal Signature of creditor/successor If applicable) Printed creditor's/successor's name Creditor's/successor's address STATE OF CALIFORNIA, COUNTY OF On before me, personally appeared (insert name and title of the signer) personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. (SEAL) Notary Public My commission expires on This form is optional. It has been approved for use in the United States Bankruptcy Court for the Central District of California. December 2012 Page 3 F 3011-1.MOTION.UNCLAIMED.FUNDS Signature of attorney/attorney-in-fact (if appointed) Printed name Address STATE OF CALIFORNIA, COUNTY OF On before me, personally appeared (insert name and title of the signer) personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. (SEAL) Notary public My commission expires on Presented by: This form is optional. It has been approved for use in the United States Bankruptcy Court for the Central District of California. December 2012 Page 4 F 3011-1.MOTION.UNCLAIMED.FUNDS PROOF OF SERVICE OF DOCUMENT I hereby certify under penalty of perjury under the laws of the United States that on , I mailed in a sealed envelope, with postage thereon fully prepaid, a fully completed true and correct copy of the document entitled: MOTION FOR ORDER RELEASING UNCLAIMED FUNDS to the United States attorney, United States trustee, and other persons and entities required to be served by LBR 3011-1(b) and addressed as follows: United States attorney Address: _____________________________ _____________________________ _____________________________ United States trustee Address: ___________________________________ ___________________________________ ___________________________________ Name and address of the trustee appointed in the case and the trustee's counsel, if any: Name and address of the Debtor, reorganized Debtor, or other fiduciary appointed to supervise the distribution of funds and assets of the estate (if not the claimant) and their counsel, if any: If Movant is not the original creditor or an employee thereof, insert the name and address of the original creditor and the creditor's counsel, if any: I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct. Date Printed Name Signature This form is optional. It has been approved for use in the United States Bankruptcy Court for the Central District of California. December 2012 Page 5 F 3011-1.MOTION.UNCLAIMED.FUNDS