CSD 4014 [4/18/17] U.S. Bankruptcy Court Southern District of California 325 West F Street San Diego, CA 92101 INFORMATION AND DOCUMENTATION REQUIRED FOR REQUESTING UNCLAIMED FUNDS Pursuant to 28 U.S.C.§ 2042, any claimant entitled to any unclaimed funds held by the court ("unclaimed funds") may, on petition to the court and upon notice to the United States Attorney and full proof of the right thereto, obtain an order directing payment to him/her. If you identify funds to which you believe you are entitled, complete the application with attached affidavit, provide information outlined below, and file the application, affidavit and supporting documents with the Court. If funds are found in multiple cases, a separate application, affidavit and supporting documentation will need to be filed in each case. Supporting documentation must be provided including proof of identity and your connection to the claim. If the claimant has changed, provide supporting documents which substantiate the change. If the applicant is claiming funds on behalf of a deceased party, the application must include a copy of the death certificate and documents that substantiate the applicant's right to act on behalf of the decedent's estate, or the applicant's right to the funds as a beneficiary of the estate. The Vendor Information Certification (form AO 213) must be completed with your Social Security or Tax ID Number. Original applications should be mailed to the court at the address listed above. All applications and affidavits must be notarized. A copy of the application, affidavit, and supporting documentation must be mailed to the United States Attorney at the address provided below and also to any other party who may have an interest in the funds. United States Attorney, 880 Front Street, Suite 6293, San Diego, CA 92101 Upon receipt, the financial department will review the application, affidavit and supporting documentation for accuracy and validity, verify that the funds remain on deposit with the court, and forward the application and supporting documentation to the Bankruptcy Judge for final disposition. Additional information may be requested to support your ownership of the funds. Any requests for unclaimed funds which appear to be based upon fraud will be referred to the U.S. Attorney for investigation and prosecution. Be sure to include the notarized original of your application and affidavit, the Vendor Information Certification and a copy of your ID. If your ID has a different address than that shown for your funds, you need to include a document that shows your name and the fund's address. A bill or statement will do, or a copy of your credit report with the previous address. Questions concerning these procedures should be directed to Russ Reynolds at the above address or call 619-557-6213 or you may e-mail your questions to russ_reynolds@casb.uscourts.gov. CSD 4014 American LegalNet, Inc. www.FormsWorkFlow.com CSD 4014[4/18/17] Name, Address, Telephone No. & I.D. No. UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF CALIFORNIA 325 West F Street, San Diego, California 92101-6991 In Re BANKRUPTCY NO. Debtor. APPLICATION AND ORDER FOR PAYMENT OF UNCLAIMED FUNDS IT IS ORDERED THAT the relief sought as set forth on the attached continuation pages is granted. ("Applicant") applies to this court for entry of an order directing the clerk to remit the sum of due to $ ("Claimant"). 1. 2. 3 4. 5. 6. 7. 8. 9. Full legal name of Claimant (If Claimant is an individual, skip to #5.) Type of Entity (corporation, LLC, partnership) State of Incorporation/Organization Name and Title of Authorizing Officer or Representative Current Mailing Address Telephone Number E-mail Address Full SS# or EIN# Amount Being Claimed The information set forth on the continuation pages By: Is APPROVED AS TO FORM: Financial Administrator, U.S. Bankruptcy Court IT IS SO ORDERED. Dated: Judge, United States Bankruptcy Court CSD 4014 American LegalNet, Inc. www.FormsWorkFlow.com CSD 4014 (Page 2) [4/18/17] ORDER ON APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS Debtor: CASE NO: AFFIDAVIT OF CLAIMANT Applicant is authorized to submit this Application and is entitled to receive the requested funds based upon: (check the applicable statement) Applicant is the original creditor or debtor and owner of the funds as it appears on the record of this Court; Applicant is the assignee of the original creditor's claim to said funds, as evidenced in the attached documentation; Applicant is the original creditor's successor in interest, as evidenced in the attached documentation; Applicant is an attorney or "funds locator" named in special/limited power of attorney, which document is attached hereto, that is valid under the laws of the State of California, that empowers Applicant to collect the unclaimed funds described above on behalf of the Claimant. Applicant states that the Claimant is the: Original creditor and owner of the claim; Original creditor's attorney with authorization to receive said funds; Assignee of the original creditor's claim to said funds; Successor in interest of the original creditor; or Personal representative of the original creditor's estate. This Application is submitted with the necessary documents to establish (1) Applicant's authority to collect the unclaimed funds on behalf of the Claimant and (2) the Claimant's entitlement to the particular unclaimed funds. The Application was completed and submitted in accordance with the Court's instructions for filing an application for payment of unclaimed funds. In accordance with 28 U.S.C. § 2042, Applicant certifies that a copy of this Application (and all attachments) have been provided to the Office of the United States Attorney on __ (date), at: United States Attorney's Office, 880 Front Street, Suite 6293, San Diego, CA 92101 Therefore, Applicant requests the Court enter an order directing payment of unclaimed funds described above to the Applicant, or if the Applicant is not the Claimant, to the Applicant and Claimant, in accordance with the documents submitted in support of the Application. Under penalty of perjury, I hereby certify that the foregoing statements are true and correct to the best of my knowledge and belief. CSD 4014 American LegalNet, Inc. www.FormsWorkFlow.com CSD 4014 (Page 3) [4/18/17] ORDER ON APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS Debtor: CASE NO: NOTARIZED SIGNATURE BLOCK FOR AN INDIVIDUAL (signature block for an entity on next page) Dated: