UNITED STATES BANKRUPTCY COURT DISTRICT OF CONNECTICUT Application for Payment of Unclaimed Funds In Re: ) ) ) Debtor(s) ) ________________________________________ ) WHEREAS I, under penalties of perjury that: Case No. Chapter , attest 1. _________________________________________________ is a creditor in this case, 2. Corporation's current address and telephone number are: 3. The original disbursement was not presented for payment within 90 days after issuance because: , , 4. Corporation is entitled to unclaimed funds in the amount of ____________________, 5. Check one: 9 I sealed this document with the corporate seal or 9 I included with this Application documentation evidencing that I have the authority to sign this Application, I HEREBY REQUEST that unclaimed dividends in the amount of __________________be made payable to ____________________________________________________ and mailed to . Signature Title Date Corporate Tax ID No./EID Corporate Seal Notary Section (include commission number and expiration date) American LegalNet, Inc. www.FormsWorkFlow.com