Affidavit For Reimbursement Of Unclaimed Dividend
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Affidavit For Reimbursement Of Unclaimed Dividend Form. This is a Florida form and can be use in USBC Northern Federal.
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Tags: Affidavit For Reimbursement Of Unclaimed Dividend, Florida Federal, USBC Northern
UNITED STATES BANKRUPTCY COURT
NORTHERN DISTRICT OF FLORIDA
IN RE:
Case No. __________________
_____________________________________
Debtor(s)
AFFIDAVIT FOR REIMBURSEMENT OF UNCLAIMED DIVIDEND
State of : ___________________ }
}
County of: __________________ }
____________________________________________________ \\being duly sworn, deposes and says:
(Name of Creditor/Claimant)
That he/she is a creditor of the above named debtor.
That __________________________________________________ was duly adjudged a debtor in the
(Name of Debtor)
United States Bankruptcy Court for the Northern District of Florida. That said creditor duly filed his/her
claim, which was thereafter duly allowed. Dividends amounting to the sum of
$____________________ remain unpaid.
That the said claim has not been sold or assigned, and that it is still the property of deponent.
It is therefore requested that the Clerk of this Court pay to:
____________________________________________________________________________ of
(Name of creditor/claimant)
_________________________________________________________________________the sum of
(Address of creditor/claimant)
$_________________.
Dated this _____ day of _______________, 20___.
___________________________________
(Signature of Creditor/Claimant)
__________________________________
(Tax identification number of creditor/claimant)
Sworn to and subscribed before me this
_____ day of ________________, 20______ by
______________________________________
(Name of claimant)
who is personally known to me or has produced
________________________ as identification.
(Type of identification produced)
______________________________________
Notary Public
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