UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF CALIFORNIA In Re: Case Number: Debtor(s). 1. On APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS [dates], a check in the amount of $ belonging to [name of original creditor/claimant] was tendered to the Clerk of the above-entitled Court by the case trustee as unclaimed funds for claim(s) numbered: 2. The funds so tendered were deposited with the United States Treasury by the Clerk and remain unclaimed. 3. Applicant alleges that the following person or entity is the owner of the funds described in paragraph 1 [provide name, address and telephone number]: ( ) 4. The original disbursement was not presented for payment because [specifically state the reason and include a brief history of the creditor/claimant from the filing of the claim to the present. Attach supporting documentation]: _______________________________________ _______________________________________ 5. Applicant represents that the alleged owner is entitled to receive the requested funds, has made sufficient inquiry and has no knowledge that any other party may be entitled to, and is not aware of any dispute regarding, the funds at issue based upon the following [check the statement(s) that apply]: a. The alleged owner is the creditor/claimant named in paragraph 1 and the owner of the funds appearing on the records of this Court, as evidenced by the attached documents. b. The alleged owner is the assignee of the creditor/claimant named in paragraph 1, or the assignee’s representative, as evidenced by the attached documents. c. The alleged owner is the successor-in-interest of the creditor/claimant named in paragraph 1, or the successor-in-interest’s representative, as evidenced by the attached documents establishing chain of ownership. d. The alleged owner is the estate of the deceased creditor/claimant named in paragraph 1, as evidenced by the attached certified copies of death certificate and other appropriate probate documents. e. Subparagraphs (a) through (d) above do not apply. As evidenced by the attached documents, the alleged owner is: EDC 3-950 (5HY ) Application for Payment of Unclaimed Funds – Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com In Re: 6. CASE NUMBER: Applicant is [check the statement that applies]: a. . The alleged owner of the funds. Attach the appropriate Identification Form for Unclaimed Funds. b. A duly authorized corporate officer (if a corporation) or a general partner (if a partnership) and is the representative of the alleged owner of the funds. Attach the appropriate Identification Form for Unclaimed Funds. c. The representative of the estate of a deceased alleged owner of the funds. Attached certified copies of probate documents which substantiates applicant’s right to act on behalf of the decedent’s estate. d. The attorney in fact for the alleged owner of the funds authorized by the attached notarized, original Power of Attorney to file e. An attorney representing the interests of the owner of the funds with authority to receive such funds, as evidenced by the this application on behalf of the alleged owner. attached notarized original Power of Attorney. 7. I understand that, pursuant to 18 U.S.C. § 152, I shall 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 or accompanying supporting documents. I further understand that any indications of fraud detected by the Court will be turned over to the U. S. Attorney for possible prosecution. 8. A copy of this completed application (with all supporting documentation) was mailed to the following on (date): (US Attorney) (Owner of the funds) (0ther) United States Attorney 501 I Street, 9th Floor Sacramento, CA 95814 WHEREFORE, applicant prays for an order directing the Clerk of the above-entitled Court to pay said tendered money to the applicant. I declare (or certify, or verify, or state) under penalty of perjury under the laws of the United States of America, that the foregoing statements and information are true and correct: Dated: Applicant’s Signature Applicant’s Name Typed or Printed Applicant’s Address ( ) Applicant’s Telephone Number EDC 3-950 (5HY ) Application for Payment of Unclaimed Funds – Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com In Re: CASE NUMBER: STATE OF , COUNTY OF On before me, personally appeared (insert name and title of 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 written 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. Notary Public (SEAL) My commission expires on FOR COURT USE ONLY File and documents reviewed by on I have carefully reviewed this application and all supporting documents and recommend to the Court that this application be approved. FinancH 'HSDUWPHQW, U.S. Bankruptcy Court EDC 3-950 (Rev. ) Date Application for Payment of Unclaimed Funds – Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com