UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF KENTUCKY IN RE: CASE NO. Debtor(s) _______________________________________ MOTION TO DISBURSE UNCLAIMED MONIES It appearing that in the above-named case a dividend check in the amount of $ made payable to , Creditor, was unnegotiated by said Creditor, the Trustee having issued a stop payment on the unnegotiated dividend check, and the Clerk having subsequently deposited the funds into the Registry Account for Unclaimed Monies to be held in said account for the benefit of the Creditor, The Creditor, , now moves this Court to order the disbursement of said funds held in the Registry Account for Unclaimed Monies, and in support of this Motion states: [Provide a brief history and possible reasons for the funds being undeliverable or check having been unnegotiated. Reference required documentation, e.g., proof of identity, affidavit with certificate of a Notary Public, and any additional supporting documents, and attach as exhibits. See "Procedures for Recovering Unclaimed Dividends" for further information regarding corporations, new ownership, and locators.] Local Form K American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, Claimant requests that the Court issue an order directing the Clerk to make disbursement of said funds held in the Registry Account for Unclaimed Monies for the benefit of the Creditor, . CREDITOR ADDRESS: PHONE NO. CERTIFICATE OF MAILING I hereby certify that on a true and correct copy of the foregoing Motion to Disburse Unclaimed Monies was served upon the Unites States Attorney for the Western District of Kentucky, Bank of Louisville Building, 510 West Broadway, Louisville, Kentucky 40202. CREDITOR Local Form K American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF KENTUCKY IN RE: CASE NO. Debtor(s) _______________________________________ ORDER TO DISBURSE UNCLAIMED MONIES The Court finds that an amount of $ Unclaimed Monies for the benefit of Creditor, deposited in the Registry Account for , for reasons stated in the Motion filed contemporaneously herewith, is due and owing to said Creditor, therefore, IT IS ORDERED that the Clerk, U. S. Bankruptcy Court, Western District of Kentucky, disburse this unclaimed dividend of $ to: Tendered by: Local Form K American LegalNet, Inc. www.FormsWorkFlow.com