(01/11) UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF COLUMBIA IN RE: ____________________, ) Case No.: ______________ Debtor. ) (Chapter ___) APPLICATION FOR RELEASE OF UNCLAIMED FUNDS PURSUANT TO 28 U.S.C. § 2042 AND BANKRUPTCY RULE 3011 AND NOTICE OF OPPORTUNITY TO OPPOSE THE APPLICATION Pursuant to 28 U.S.C. § 2042 and Federal Rule of Bankruptcy Procedure 3011, _______________________________, Applicant, reports as follows: 1. Application is hereby made for unclaimed funds that are owed to the Applicant in this case in the amount of $_________.____. These funds were deposited into the Registry of the Court pursuant to 11 U.S.C. § 347 after a for the sum was not cashed. check to 2. The reason why the funds went unclaimed is that _______________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________. 3. The Applicant certifies that the Applicant is the entity entitled to a return of the unclaimed funds. If the payee on the check was a creditor in the case, the claim of the creditor has not been satisfied from other sources, and the amount of the claim that remains unpaid is equal to or exceeds the amount of the unclaimed funds. 4. An account record regarding amounts owed on the debt: [ ] was not maintained; [ ] was maintained and a copy of the page stating the balance currently owed is attached hereto; [ ] was maintained but is unavailable because ______________________ ______________________________________________________________________ ______________________________________________________________________ but I can certify that the debt remains unpaid because _____________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________. 5. I have attached hereto _____ page(s) (if any) further explaining my Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com (01/11) Application and ______ page(s) of documents in support of this Application1. Each document is a true copy of a genuine document. I am additionally separately filing a Statement of Social Security Number or Taxpayer Identification Number in Support of Application for Release of Unclaimed Funds. 6. The Applicant requests that the said unclaimed funds be returned to: _______________________________________ _______________________________________ _______________________________________ I declare under penalty of perjury that the foregoing is true and correct. Executed on this ___ day of ________, _______. Signature: __________________________________ Telephone No.: ____________ Printed Name:_______________________________ See the instructions contained in the court website's Information Regarding Unclaimed Funds for the documents that must accompany application. Page 2 of 3 1 American LegalNet, Inc. www.FormsWorkFlow.com (01/11) NOTICE IS HEREBY GIVEN THAT ANY OBJECTION TO THIS APPLICATION MUST BE FILED WITHIN 21 DAYS AFTER THE DATE OF SERVICE NOTED BELOW. CERTIFICATE OF SERVICE I hereby certify that copies of the foregoing Application were mailed, postage prepaid, this _____day of ________________ , ________, to: _______________________________, Trustee ______________________________________ ______________________________________ ______________________________________ United States Attorney's Office 555 4th Street, N.W. - 5th Floor Washington, DC 20001 Office of United States Trustee 115 South Union Street Suite 210 Alexandria, VA 22314 ________________________________ Signature ________________________________ Printed Name Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com