UNITED STATES BANKRUPTCY COURT DISTRICT OF HAWAII Case No.: Debtor: Joint Debtor: Chapter: APPLICATION FOR UNCLAIMED FUNDS 1. Claim Information Application is hereby made for disbursement of the following previously unclaimed funds on deposit with the court for the benefit of the claimant named below. Amount: Claimant’s Name: Claimant’s Address: (at time claim was made) *Provide documentation that Claimant resided or did business at this address. Claimant’s Current Address: (if different from above) Last 4 digits of Claimant’s SSN or Complete EIN 2. Applicant Information The applicant is: The individual claimant named above. Photo identification is attached. An individual authorized to act on behalf of the corporation, partnership, limited liability company, or other artificial entity named above. Documentation showing authority to make this application is attached. The legal representative of the claimant named above. An original, notarized power of attorney is attached, or, if the claimant is deceased, a certified copy of a letter of administration or probated will is attached. The successor in interest to the claimant named above. Documentation showing entitlement to the funds through amendment, merger, or dissolution is attached. 3. Service on United States Attorney The undersigned understands that a copy of this application and supporting documentation must be sent to the United States Attorney at the following address: Office of the United States Attorney District of Hawaii 300 Ala Moana Boulevard, Room 6100 Honolulu, HI 96850. hib_3011 01/08 American LegalNet, Inc. www.FormsWorkflow.com 4. Declaration The undersigned declares, under penalty of perjury, that the information contained in this application and any accompanying documentation is true and correct. I also understand that, pursuant to 18 U.S.C. § 152, I may be fined not more than $250,000, or imprisoned not more than 5 years if I have knowingly and fraudulently made any false statements in this document or provided false documentation as part of this application. ___________________________ Date ___________________________ Signature of Applicant Phone: _____________________ Address: ___________________________________________________ Email: _________________________ ___________________________ Printed Name of Applicant ___________________________________________________ ___________________________________________________ 5. Notarization STATE OF ____________________________, COUNTY OF __________________________________________ On ________________________, before me, personally appeared ___________________________________. The applicant who signed above is personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument. WITNESS my hand and official seal. (SEAL) ___________________________________ Notary Public My commission expires on: _________________________ This application may be filed with the court at the following address: UNITED STATES BANKRUPTCY COURT DISTRICT OF HAWAII 1132 Bishop Street, Suite 250L Honolulu, HI 96813. hib_3011 01/08 American LegalNet, Inc. www.FormsWorkflow.com UNITED STATES BANKRUPTCY COURT DISTRICT OF HAWAII Case No.: Debtor: Joint Debtor: Chapter: Name of Claimant: Applicant’s Name and Address: (Check will be sent to this address) VERIFICATION OF FUNDS ON DEPOSIT The court’s financial records indicate that funds in the following amount are being held for the claimant named above: $ ___________________ _________________________ Date ________________________________ Deputy Clerk STATEMENT BY UNITED STATES ATTORNEY The undersigned is authorized to make this statement on behalf of the United States Attorney for the District of Hawaii. The United States Attorney has no objection to the payment of unclaimed funds to the applicant named above. _________________________ Date ________________________________ for the United States Attorney ORDER APPROVING APPLICATION FOR UNCLAIMED FUNDS For good cause, IT IS HEREBY ORDERED that the application for unclaimed funds is APPROVED. The clerk may disburse the above amount of funds to the applicant named above. _________________________ Date hib_3011 01/08 ________________________________ United States Bankruptcy Judge American LegalNet, Inc. www.FormsWorkflow.com