Individual Form UNITED STATES BANKRUPTCY COURT DISTRICT OF MASSACHUSETTS INDIVIDUAL IDENTIFICATION FORM FOR UNCLAIMED FUNDS Case Name ____________________________________________________________________ Case No. _______________ Amount of dividend/refund ___________________ A dividend/refund check was previously issued in your name in accordance with an Order of this Court; however, said check was not cashed and has been deposited with the United States Treasury. In order to insure payment to the proper party, please fill out the identification portion on this form and mail it with a copy of a government issued photo ID to: U.S. Bankruptcy Court Attn: Finance Department John W. McCormack Post Office and Court House 5 Post Office Square, Suite 1150 Boston, MA 02109-3945 Upon receipt of the completed document your request for payment of unclaimed funds held by the Court will be processed. Please note that additional documentation or proof of ownership or transfer of ownership may be required. I, __________________________________________________________, hereby state that I am a creditor/debtor in the above-named proceeding and request payment of my unclaimed dividend/refund check. Old Address __________________________________________________________________ Current Address _______________________________________________________________ Driver's license no. _______________ State _________ ______________________________ (Signature) NOTARY PUBLIC State/Commonwealth of _____________________ County of ____________________________ The above named __________________________________________ personally appeared before me. She/he is known to me to be the person holding the office and authority represented and he/she acknowledges the foregoing to be his/her free act. DATE: __________ ___________________________ My commission expires: (Notary Public)(Notary Seal) 5 _____________ 5 For documents signed and notarized outside the United States, please contact the Embassy of the country of origin (where you are having the document notarized) for assistance. American LegalNet, Inc. www.FormsWorkFlow.com