Revised 7/2018 UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF MICHIGAN In re: Case No. Chapter 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 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 fund for . The applicant further states that: 1. (Indicate one of the following) Applicant is the party requesting payment of the unclaimed fund named above and states that no other application for this unclaimed fund has been submitted by or at the request of the claimant. Applicant is the duly authorized representative for the business or corporation named above as the claimant. Applicant has reviewed all records of the claimant and states that no other application for this claim has been submitted by or at the request of this claimant. An Affidavit of Claimant is attached and made part of this application. Applicant is either a family member of the deceased claimant or a successor in interest to the individual or business named as the claimant. An original 223power of attorney224 conforming to the official Bankruptcy Form and/or other supporting documents which indicated the applicant222s entitlement to this claim is attached and made part of this application. American LegalNet, Inc. www.FormsWorkFlow.com 2. 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. Application for Payment of Unclaimed Funds Respectfully submitted this day of 20 Name of Applicant Signature of Applicant Name and Title of Applicant Company Name Street Address City and State Telephone number Tax Identification XXX-XX- Social Security Number Claim Number, if applicable American LegalNet, Inc. www.FormsWorkFlow.com