CSD 4014A_individual [04/18/17] 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 claimant is claiming funds on behalf of a deceased party, the application must include a copy of the death certificate and documents that substantiate the claimant's right to act on behalf of the decedent's estate, or the claimant'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 4014A_individual American LegalNet, Inc. www.FormsWorkFlow.com CSD 4014A_individual[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. ("Claimant") applies to this court for entry of an order directing the clerk to remit the sum of $ 1. 2. 3. 4. 5. Full legal name of Claimant Current Mailing Address Telephone Number E-mail Address Full SS# or EIN# 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 4014A_Individual American LegalNet, Inc. www.FormsWorkFlow.com CSD 4014A_individual (Page 2) [4/18/17] ORDER ON APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS Debtor: CASE NO: AFFIDAVIT OF CLAIMANT Claimant is authorized to submit this Application and is entitled to receive the requested funds based upon: (check the applicable statement) Claimant is the original creditor or debtor and owner of the funds as it appears on the record of this Court; Claimant is the assignee of the original creditor's claim to said funds, as evidenced in the attached documentation; Claimant is the original creditor's successor in interest, as evidenced in the attached documentation; This Application is submitted with the necessary documents to establish 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, Claimant 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, Claimant requests the Court enter an order directing payment of unclaimed funds described above to the 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 4014A_individual American LegalNet, Inc. www.FormsWorkFlow.com CSD 4014A_individual (Page 3) [4/18/17] ORDER ON APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS Debtor: CASE NO: NOTARIZED SIGNATURE BLOCK FOR AN INDIVIDUAL Dated: Signature of Individual Claimant Print Name: Street Address: City/State/Zip: Telephone (including area code): State of County of ) )ss. ) Before me, , 20 , a notary public for said state, on this , personally appeared day of known to be the identical person(s) who executed the within foregoing instrument, and acknowledge to me that he/she executed the same as his/her free and voluntary act and deed for the uses and purposes therein set forth. [SEAL] Notary Public My commission expires: CSD 4014A_individual American LegalNet, Inc. www.FormsWorkFlow.com