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Affidavit Of Claimant Form. This is a Florida form and can be use in USBC Southern Federal.
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Tags: Affidavit Of Claimant, LF-28, Florida Federal, USBC Southern
UNITED STATES BANKRUPTCY COURT
SOUTHERN DISTRICT OF FLORIDA
www.flsb.uscourts.gov
In re:
Case No.
Chapter
Debtor
/
AFFIDAVIT OF CLAIMANT
I,
claimant)
, am (indicate status of
( ) the individual creditor (or authorized personal representative of the
individual creditor) in whose name funds were deposited with the court who has
granted a power of attorney to
,
a “funds locator” or attorney to submit an application to withdraw unclaimed funds
on my behalf; or
(
) the duly authorized representative for the claimant "business"
; or
( ) the debtor claiming funds deposited in the name of a creditor in this case
who has granted a power of attorney to
a “funds locator” or attorney, to submit an application on my behalf; or
,
( ) the debtor claiming funds deposited in the name of the debtor in this case
who has granted a power of attorney to
,
a “funds locator” or attorney, to submit an application on my behalf; or
( ) the duly authorized representative for claimant "business" as indicated in the
attached corporate power of attorney who has granted a power of attorney to
a “funds locator” or attorney,
to submit an application to withdraw unclaimed funds on my behalf;
and I am seeking payment of unclaimed funds in the amount of $
deposited in this court in the name of
and
representing claim number
(if no claim was filed write “scheduled"
in blank space).
2. Claimant History: Substantiate claimant's right to funds, including but not
limited to documents relating to sale of company, i.e. purchase agreements and/or
stipulation by prior and new owner as to right of ownership of funds. Attach certified
copies of all necessary documentation, including those which establish the chain of
LF-28 (rev. 06/02/08)
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ownership of the original corporate claimant. Also attach a copy of an official
government photo id to prove your identity.
3. I (or the "business" I represent as claimant) have neither previously received
remittance for these funds nor have contracted with any other party other than the
person named as a “funds locator” or attorney in paragraph 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.
signature of claimant or representative of “business”
claimant
Dated:
print name
title
Last Four Digits of Social Security # or Tax ID# (EIN #)
(Note: attach a copy of an official government photo
id such as a driver’s license or passport”)
address
Phone number
signature of joint debtor (if applicable)
print name
Last Four Digits of Social Security # or Tax ID# (EIN #)
(Note: attach a copy of an official government photo
id such as a driver’s license or passport”)
Sworn to and Subscribed before me
on
.
NOTARY PUBLIC, AT LARGE
STATE OF
LF-28 (rev. 06/02/08)
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