UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF CALIFORNIA APPLICATION FOR UNCLAIMED FUNDS Debtor 1: Case No.: Debtor 2 (if applicable): Chapter: 1.Claim Information For the benefit of the Claimant(s) named below, application is made for the disbursement of unclaimed funds on deposit with the court. I have no knowledge that any other party may be entitled to these funds, and I am not aware of any dispute regarding these funds. NOTE: If there are joint claimants, complete the fields below for both claimants. Claimant Joint Claimant Amount: Claimant222s Name: Claimant222s Current Mailing Address Telephone e-mail address: 2.Applicant Information Applicant represents that Claimant is entitled to receive the unclaimed funds based upon (check the statements that apply): Claimant is the Owner of Record entitled to the unclaimed funds appearing on the records of the court.Applicant is Claimant222s on-ttorney epresentative (e.g., nclaimed unds ocator.)Applicant is Claimant222s ttorney.Applicant is a epresentative of eceased Claimant222s estate. American LegalNet, Inc. www.FormsWorkFlow.com Debtor Name: Case Number: 3.Supporting Documentation Applicant has read the court222s instructions for filing an Application for Unclaimed Funds and is providing the required supporting documentation with this application. 4.Service on United States AttorneyApplicant understands that a copy of this application and supporting documentation must be sent to the United States Attorney, pursuant to 28 U.S.C. 247 2042, at the following address: 5.Applicant DeclarationPursuant to 28 U.S.C. 247 1746, I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct. Date: Signature of Applicant Printed Name of Applicant Telephone: Email: 5.Co-Applicant Declaration (if applicable)Pursuant to 28 U.S.C. 247 1746, I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct. Date: Signature of Applicant Printed Name of Applicant Telephone: Email: American LegalNet, Inc. www.FormsWorkFlow.com Debtor Name: Case Number: 6.Notarization STATE OF COUNTY OF This Application for Unclaimed Funds, dated was subscribed and sworn to before me this day of , 20 by who signed above and is personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument. WITNESS my hand and official seal. Notary Public: My commission expires: (SEAL) 6.Notarization STATE OF COUNTY OF This Application for Unclaimed Funds, dated was subscribed and sworn to before me this day of , 20 by who signed above and is personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument. WITNESS my hand and official seal. Notary Public: My commission expires: (SEAL) American LegalNet, Inc. www.FormsWorkFlow.com Debtor Name: Case Number: CERTIFICATE OF SERVICE I declare under penalty of perjury that on, I mailed in a sealed envelope with prepaid postage, a true and correct copy of the completed APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS to the United States attorney222s office. United States Attorney 501 I Street, Suite 10-100 Sacramento, CA 95814 Name and address of , if any I declare under penalty of perjury under the laws of the United States that the information provided above is true and correct. Date American LegalNet, Inc. www.FormsWorkFlow.com AO 213 (Rev. 0) ADMINISTRATIVE OFFICE OF THE UNITED STATES COURTSAccounting DivisionVENDOR INFORMATION/TIN CERTIFICATIONMandatory Information that MUST be provided before submissionEx-AO EmployeeSAM Vendor(Formerly CCR)(No TIN Certification Required)Vendor AddressOther Address (If different from Vendor Address)Select all that apply Order Remit 1099Select all that apply Order Remit 1099Name:Address:Business Name:(if different from above)City:Address 1:State:Zip Code:Address 2:Phone #:City:Description: (If needed)State:Zip Code:Phone #:E-mail:Taxpayer Identification #:(TIN, SS, or EIN number)DUNS # Financial Information Bank Name:Routing # (this nine digit number appears on yourchecks, but do not include individual check numbers):City:Account #:State:Zip Code:Type of Account: (select one) Checking SavingsType of Organization for 1099 reporting: sole proprietorship; partnership; corporate entity (not tax-exempt); corporate entity (tax-exempt); health care provider; other: government entity (write in either federal, state or local) Taxpayer Identification Number CertificationUnder penalties of perjury, I certify that: 1.The Taxpayer Identification Number listed in the Vendor Address area above is the correct number assignedto me, and2.I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have notbeen notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of afailure to report all interest and dividends, or (c) the IRS has notified me that I am no longer subject to thebackup withholding, and3.I am a U.S. citizen or other U.S. person (defined below).You must select this check box if you have been notified by the IRS that you are currently subject to backup withholding becauseyou have failed to report all interest and dividends on your tax return. If you make a false statement with no reasonable basis thatresults in no backup withholdings, you are subject to a $500 penalty. Willfully falsifying certifications or affirmations on thisform may subject you to criminal penalties including fines and/or imprisonment.Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com AO 213 (Rev. 0) Definitions:"Taxpayer Identification (TIN, SS, or EIN number)" is the number required by the Internal Revenue Service (IRS) to be used in reporting income tax and other returns. The TIN may be either a social security number (SSN) or an employer identification number (EIN)."U.S. person" means:!An individual who is a U.S. citizen or U.S. resident alien,!A partnership, corporation, company, or association created or organized in the United States or under the laws ofthe United States.The TIN, as well as the information above is required in order to comply with debt collection requirements of 31 U.S.C. 247247 7701(c) and 3325(d) , reporting requirements of 26 U.S.C. 247247 6041 and 6041A , and implementing regulations issued by the IRS. Failure orrefusal to furnish this information may result in 28 percent backup withholding on any payments otherwise due under any awardedcontract or purchase order.The TIN may be used by the government to collect and report on any delinquent amounts arising out of the vendor's relationship withthe government (31 U.S.C. 247 7701(c)(3)) . The TIN provided may be matched with IRS records to verify its accuracy.Complete this section only if a TIN was not provided on page one, and select closest reason why not:The vendor is a nonresident alien, foreign corporation or foreign partnership that does not have income effectivelyconnected with the conduct of a trade or business in the United States and does not have an office or place of businessor a fiscal paying agent in the United States; The vendor is an agency or instrumentality of a foreign government;Additional information required for vendors used for procurement(purchase orders, contracts, etc.)Indicate which, if any, of the following categories are applicable. These categories require that the vendor is 51% owned and themanagement and daily operations are controlled by one or more members of the selected socio-economic group: Women Owned BusinessNot Applicable Minority Owned Business (If yes, select one of the owner's race/ethnicity selections from below): Asian-Pacific American Black AmericanSubcontinent Asian (Asian-Indian)American Hispanic American Native American Other:Date:Vendor222s signatureFor Agency Use OnlyThe vendor name and DUNS number is all that is required for registered System for Award Management (SAM) vendors (formerlyCCR). (Check www.sam.gov for registration status.) Do not use this form for purchase card merchants. Mark Boxes that apply:Addition