UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF FLORIDA IN RE: CASE NO. __________________ _____________________________Debtor(s) / APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS ____________________________ _______ (“Applicant”) applies to this Court for entry of an order directing the clerk to remit the sum of $ _______________ due to ______ ___________________ (“Claimant”). 1. 2. Full legal name of Claimant (If Claimant is an individual, skip to #5.) Type of Entity 3. State of Incorporation/Organization 4. 5. Name and Title of Authorizing Officer or Representative Current Mailing Address 6. Telephone Number 7. SS# (last 4 digits only) or EIN # 8. Amount Being Claimed (corporation, LLC, partnership) Applicant represents that Applicant is authorized to submit this Application and is entitled to receive the requested funds based upon: (check the applicable statement) o o o o Applicant is the original creditor and owner of the funds as it appears on the records of this Court; Applicant is the assignee of the original creditor’s claim to said funds, as evidenced in the attached documentation; Applicant is the original creditor’s successor in interest, as evidenced in the attached documentation; Applicant is an attorney or “funds locator” named in a special/limited power of attorney, which document is attached hereto, that is valid under the laws of the State of Florida, that empowers Applicant to collect the unclaimed funds described above on behalf of the Claimant. Applicant states that the Claimant is the: (check the applicable statement) o Original creditor and owner of the claim; o Original creditor’s attorney with authorization to receive said funds; o Assignee of the original creditor’s claim to said funds; o Successor in interest of the original creditor; or o Personal representative of the original creditor’s estate. American LegalNet, Inc. www.FormsWorkFlow.com This Application is submitted with the necessary documents to establish (1) Applicant’s authority to collect the unclaimed funds on behalf of the Claimant and (2) 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, Applicant certifies that a copy of this Application (and all attachments) have been provided to the Office of the United States Attorney on (date), at: (check the applicable location) o o (Gainesville, Tallahassee, and Panama City Divisions) 110 N. Adams St., 4th Floor, Tallahassee, FL 32301 (Pensacola Division) 21 E. Garden St., Ste. 400, Pensacola, FL 32502 Therefore, Applicant requests the Court enter an order directing payment of unclaimed funds described above to the Applicant, or if the Applicant is not the Claimant, to the Applicant and 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. SIGNATURE BLOCK FOR AN INDIVIDUAL (signature block for an entity on next page) Dated: Signature of Individual Applicant Print Name: Street Address: City/State/Zip: Telephone (including area code): State of ) ) ss. ) County of Before me, , a notary public for said state, on this , 20 day of , personally appeared ___________________________________ 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: American LegalNet, Inc. www.FormsWorkFlow.com SIGNATURE BLOCK FOR AN ENTITY (signature block for individual on previous page) Dated: Name of Applicant (entity) By Print Name and Title: Street Address: City/State/Zip: Telephone (including area code): State of County of ) ) ss. ) Before me, , a notary public for said state, on this , 20 as day of , personally appeared ___________________________________ [capacity, e.g. president, treasurer] who executed the within foregoing instrument on behalf of [name of entity], and acknowledged to me that he/she executed the same as his/her free and voluntary act and deed on behalf of said [type of entity, e.g. corporation, limited liability company, partnership] for the uses and purposes therein set forth. [SEAL] Notary Public My commission expires: American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF FLORIDA IN RE: CASE NO. __________________ _____________________________Debtor(s) / AFFIDAVIT OF CLAIMANT I, , the undersigned claimant [or duly authorized representative for the claimant as identified in paragraph (2)], declare as follows: 1. I [Claimant or authorized representative of Claimant that has been granted a power of attorney to submit for claimant as indicated in the attached power of attorney] am seeking payment of $ held in the registry of the Court. 2. My name, position with company [if applicable], address and telephone number are as follows: 3. Copies of all necessary documentation, including those which establish the chain of ownership of the original corporate creditor [e.g. documents relating to a sale of company, purchase agreements and/or stipulation by prior and new owner as a right of ownership of funds] and which substantiate claimant’s right to the funds, are attached. 4. I [or the business that I represent as claimant] have neither previously received these funds nor contracted with any other party other than the person named in item one above to recover these funds. I hereby certify that the foregoing statements are true and correct to the best of my knowledge and belief. Dated: Signature of Claimant or duly authorized representative Print Name: Title: Sworn to and subscribed before me this day of , 20 . [SEAL] Notary Public In and for the State of My commission expires: American LegalNet, Inc. www.FormsWorkFlow.com