UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF CALIFORNIA IN RE: ) ) ) ) ) ) ) ) CASE NO: CORPORATION/BUSINESS IDENTIFICATION FORM FOR UNCLAIMED FUNDS DEBTOR(S). I, ___________________________________________, hereby state that I am the of unclaimed funds. Current Telephone No. Tax Identification No. Previous Mailing Address Current Mailing Address Dated: ( ) (Title) (Business Name), and I am authorized to request payment of (SEAL*) Signature * Affix seal, if available, and attach appropriate documentation which indicates that the person signing is authorized to do so. This documentation should be a corporate power of attorney signed by the CEO of the company (or other corporate officer) and a statement of the signing officer's authority, or similar documentation, as well as documents establishing the chain of ownership of the original corporate/business claimant, if appropriate. STATE OF On , COUNTY OF 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 To ensure payment to the proper party, please fill out the identification portion of this form and submit together with an Application for Payment of Unclaimed Funds (EDC 3-950) and supporting documentation to: Financial Administrator United States Bankruptcy Court Eastern District of California 501 I Street, Suite 3-200 Sacramento, CA 95814 EDC 3-952 (New 11/01) 2002 © American LegalNet, Inc.