(rev 5/29/12) UNITED STATES BANKRUPTCY COURT Southern District of Indiana In re: [Name of Debtor(s)], Debtor(s). ) ) ) ) Case No. (xx-xxxxx) TRUSTEE'S NOTICE OF UNCLAIMED DIVIDENDS Pursuant to Fed.R.Bankr.P. 3011, (trustee name), trustee herein, submits the following notice of unclaimed dividends to the Court. Payee(s) (Limit the number of claimants to 250 per notice.) Last Known Address(es) Amount(s) ___________ TOTAL AMOUNT: $ /s/ (Name of Trustee) (Name of Trustee) (required signature block) (NOTE: All checks should be mailed to the Indianapolis Clerk's Office, 116 U.S. Courthouse, 46 East Ohio Street, Indianapolis, Indiana, 46204, and not to the divisional offices. Attach a copy of this notice to the check. Only remit one check per notice regardless of whether 1 or 250 claimants are listed on this notice.) American LegalNet, Inc. www.FormsWorkFlow.com