IN THE UNITED STATES BANKRUPTCY COURT (version 6/16) FOR THE DISTRICT OF KANSAS In re: [Debtor(s) name(s)] Debtor. Case No. Chapter VERIFIED PETITION FOR PAYMENT OF UNCLAIMED FUNDS 1. The undersigned [claimant], hereby requests that the Court enter an Order Directing Payment of Unclaimed Funds, and in support of the petition states: 2. In the case identified in the caption above, a check(s) issued to [owner of record] in the following amount(s) was (were) tendered to the Clerk of Bankruptcy Court as unclaimed funds: 3. The owner of record did not receive or negotiate the check(s) for the following reason(s): 4. Claimant is entitled to receive the requested funds based upon the following: [Check the statement that applies. Please redact all supporting documents as instructed by Fed. R. Bankr. P. 9037:] 037 Claimant is the owner of record of the funds as indicated on the records of this Court, as shown by the attached documents, including a copy of the photo identification of the owner of record. 037 Claimant is the attorney in fact for the owner of record and is authorized by the owner of record to submit this petition, as shown by the following documents: a copy of the photo identification of the owner of record; an attached notarized, original power of attorney authorizing the claimant to file this petition on behalf of the owner of record; a photocopy of the photo identification of the attorney in fact; and documentation establishing the owner of record222s entitlement to the funds. American LegalNet, Inc. www.FormsWorkFlow.com 037 Claimant is entitled to the funds as a successor business or assignee as shown by the following documents: proof of identity of the owner of record; a notarized power of attorney signed by an officer of the successor business or the assignee; a statement of the signing officer222s authority; and documentation establishing chain of ownership from the original business claimant. 037 Claimant is the representative of the owner of record222s estate (i.e., administrator, executor, or representative) as shown by the following documents: proof of identity of the owner of record; proof of personal identity of the estate administrator; certified copies of probate documents establishing the representative222s right to act on behalf of the decedent222s estate. 5.Claimant has no knowledge that any other party may be entitled to these funds and is notaware of any dispute regarding these funds. 6.The Social Security Number (SSN) or Tax Identification Number (TIN) of the owner of recordis provided to the court on the enclosed IRS Form W-9 Request for Taxpayer Identification Number and Certification. [Please include the full SSN or TIN.] Wherefore, claimant requests that the Court enter an Order Directing Payment of the Unclaimed Funds described above to: Claimant222s Name: Fund Locator222s Name (if applicable): Address Email Address: (optional): Telephone Number (optional): Pursuant to 11 U.S.C. 247 1746, I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct. Claimant222s Signature Date American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF SERVICE Pursuant to 28 U.S.C. 247 2042 and Local Bankruptcy Rule 2002.2(b), on [date], claimant mailed a copy of this completed petition (with all supporting documentation) to [check the appropriate box]: 037 Office of United States Attorney Robert J. Dole U.S. Courthouse, Ste 360 500 State Avenue Kansas City, KS 66101 037 Office of United States Attorney U.S. Courthouse, Suite 290 444 Southeast Quincy Street Topeka, KS 66683 037 Office of United States Attorney 1200 Epic Center 301 N. Main Wichita, KS 67202 Claimant222s Signature Date American LegalNet, Inc. www.FormsWorkFlow.com