U.S. BANKRUPTCY COURT NORTHERN DISTRICT OF FLORIDA IN RE: Case No. ________________ __________________________________ Debtor(s) AFFIDAVIT OF CLAIMANT State of ________________} } County of ______________} I (we), ___________________________________________________________, the undersigned claimant(s) declare as follows: 1. I am seeking funds deposited in the registry of the court in the amount of ___________________. 2. I am the individual claimant named in the Notice of Payment of Funds to the Registry. 3. I have neither previously received remittance of these funds nor have contracted with any other party to recover these funds. 4. I have provided notice to the U.S. Attorney pursuant to 28 U.S.C. § 2042. I hereby certify that the foregoing statements are true and correct to the best of my knowledge and belief. Dated: ___________________ _________________________________ Signature of claimant _________________________________ Signature of claimant _________________________________ Print name(s) _________________________________ Address _________________________________ _________________________________ Tax I.D. Number(s) 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 American LegalNet, Inc. www.FormsWorkflow.com