UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF CALIFORNIA IN RE: ) ) ) ) ) ) ) CASE NO: INDIVIDUAL IDENTIFICATION FORM FOR UNCLAIMED FUNDS DEBTOR(S). I, ___________________________________________, hereby allege that I am the owner of unclaimed funds deposited with the court in the above-named case and request payment of my unclaimed funds. Name Current Phone No. Social Security No. Previous Mailing Address Current Mailing Address Driver's License No. (0r other State issued Identification No.) Dated: Signature of Alleged Owner * * Attach copy of Driver's License or other State issued Identification. In the case where a "fund locator service" has purchased/been assigned the claim, or purchased the assets of the business originally entitled to the funds, documents evidencing the transfer of claim or documentation which provides proof of the purchase/sale of the assets (such as the contract of sale) must be attached. ( ) (Describe) 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 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. 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 3-951 (New 11/01) 2002 © American LegalNet, Inc.