UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF MICHIGAN In re: Case No. Chapter 13 ORDER FOR PAYMENT OF UNCLAIMED FUNDS Upon application and in accordance with the provisions of 28 U.S.C. Section 2042, that following a review of the sufficiency of the Affidavit of Claimant information that the claimant is properly entitled to said funds, and that the U.S. Attorney for the Eastern District of Michigan was provided a copy of this application with a proof of service attached to the application, IT IS ORDERED that the Clerk of the U.S. Bankruptcy Court remit to , the sum of dollars ($ ), of unclaimed funds held in the U.S. Treasury. ________________________________ United States Bankruptcy Judge Dated: _____________________ Katherine B. Gullo, Clerk U.S. Bankruptcy Court By: Deputy Clerk American LegalNet, Inc. www.FormsWorkflow.com UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF MICHIGAN In re: Case No. __________________ Chapter 13 APPLICATION FOR PAYMENT FROM UNCLAIMED FUNDS The undersigned, __________________________________, applies to the Bankruptcy Court for the Eastern District of Michigan for entry of an order directing the Clerk of the Court to remit to the applicant the sum of $___________________ , said funds having been deposited into the Treasury of the United States pursuant to an order of the Court as unclaimed funds for creditor . The applicant further states that: 1. (Indicate one of the following) _____ _____ _____ 2. Applicant is the creditor named in the above case and states that no other application for this claim has been submitted by or at the request of the creditor Applicant is the duly authorized representative for the business or corporation named as the creditor. Applicant has reviewed all records of the creditor and states that no other application for this claim has been submitted by or at the request of this creditor. An Affidavit of Creditor is attached and made part of this application. Applicant is either a family member of the deceased creditor or a successor in interest to the individual or business named as the creditor. An original “power of attorney” conforming to the official Bankruptcy Form and/or other supporting documents which indicated the applicants’ entitlement to this claim is attached and made part of this application. Applicant has made sufficient inquiry and has no knowledge that this claim has been previously paid, that any other application for this claim is currently pending before this court, or that any party other than the applicant is entitled to submit an application for this claim. American LegalNet, Inc. www.FormsWorkflow.com Page 2 of 2 Application for Payment from Unclaimed Funds Respectfully submitted this _____ day of ____________, 20___. ___________________________ Name of creditor _____________________________ Signature of Applicant __________________________________ Name and Title of Applicant __________________________________ Company Name __________________________________ Street Address __________________________________ City and State __________________________________ Telephone number __________________________________ Tax Identification XXX-XXSocial Security Number _ ______________ Claim Number American LegalNet, Inc. www.FormsWorkflow.com UNITED STATE BANKRUPTCY COURT EASTERN DISTRICT OF MICHIGAN In re: Case No. ______________________ Chapter 13 AFFIDAVIT OF CLAIMANT I, ________________________________________________, do hereby state that I am the claimant to the unclaimed funds released in this application and that I am, to the best of my knowledge, the legal owner of these funds. Mailing address: ____________________________________ Phone number: Social security number XXX-XXIf claimant is a corporation, the federal tax ID number 1. Claimant History: Substantiate claimant’s right to the claim; i.e. if the payment is to an individual, include a copy of driver’s license or state identification card. If a corporation, include purchase agreements regarding the right to ownership. Attached are certified copies of all necessary documentation. 2. I (or the company which I represent) neither have previously received remittance for this claim nor contracted with any other party other than the person named in item one above to recover these funds. American LegalNet, Inc. www.FormsWorkflow.com Page 2 of 2 Affidavit of Claimant I declare under penalty of perjury that the foregoing copy is true and correct. Dated: __ _________ ___ Signature of Claimant Sworn to and Subscribed before me this ____ day of _________________, 20___ __________________________________ NOTARY PUBLIC AT LARGE STATE OF ________________________ American LegalNet, Inc. www.FormsWorkflow.com UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF MICHIGAN In re: Case No. ______________________ Chapter 13 PROOF OF SERVICE I, the undersigned, hereby certify that on the ______ day of ________________, 20 , a copy of the Application for Payment From Unclaimed Funds by was served on the United States Attorney for the Eastern District of Michigan at the following address: U.S. Attorney for the Eastern District of Michigan Attn.: Michael Wicks, Civil Division-Financial Litigation 211 West Fort Street, Suite 2001 Detroit, MI 48226-3211 Dated: By: American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR COMPLETING APPLICATION AND AFFIDAVIT FOR PAYMENT OF UNCLAIMED FUNDS A. Steps For Completing The Application 1. Enter the name of the case (name of the debtor) either to the right or under where In Re: is typed. 2. Enter the case number. 3. Enter the name of the person completing the application. 4. Enter the amount being held by the Court in the unclaimed funds account. 5. Enter the name of the creditor. This would be the same entry as in step #4 if the creditor is applying on behalf of his or her self. If the creditor is a company, enter the company's name as it appeared on it's proof of claim. If the company applying for unclaimed funds is not the same as the name originally filed, enter the name of the company applying. You will have to show proof as to why the new company or entity is entitled to the funds (see step #6 describing part 3 of the Affidavit of Creditor). 6. Make an "X" or check mark for whichever choice is appropriate. 7. Date. 8. Name of creditor 9. Signature of Applicant. 10 Address, telephone number and last four digits of a social security number or complete tax identification number of the creditor. 11. Claim number. American LegalNet, Inc. www.FormsWorkflow.com B. Steps For Completing The Affidavit 1. Same as steps #1 thru #4 in instructions for application. 2. Enter the name, position with the company if applicable, address and telephone number of the person signing the affidavit on page 2. 3. Attach proof of creditor's right to the unclaimed funds as described in item #3 of the affidavit. Other examples of proof might be a copy of a driver's license, articles of incorporation, dissolution papers, copy of the proof of claim filed with the Court, etc.. If sufficient proof of the creditor's right to the funds is not provided, the application may be denied. 4. The notarized signature of the person shown in step #5. C. Steps For Completing the Proof of Service 1. Same steps as #1 and #2 in the instructions for application. 2. The day a copy of the application was mailed to the U.S. Attorney. 3. The applicant/creditor completing the application. 4. The day the form was signed (if different form the date in item #2). 5. The signature of the person mailing the application to the U.S. Attorney. D. Steps for completing the Order For Payment Of Unclaimed Funds 1. Same as steps #1 and #2 of the application. 2. The written amount of funds payable. 3. The numeric amount of funds payable. American LegalNet, Inc. www.FormsWorkflow.com