United States Bankruptcy Court Western District of Michigan One Division Avenue North, Room 200 Grand Rapids, MI 49503 Application for Release of Unclaimed Funds The burden of proof lies with the claimant to show legal ownership of unclaimed funds. The Court requires that you supply at least two (2) forms of evidence that the claimant is the party legally entitled to funds held in the registry of the Court. SUGGESTED FORMS OF EVIDENCE (*indicates required documentation): Individual: *W-9 *Copy of Driver's License *Copy of Social Security Card Copy of Marriage Certificate or Divorce Decree (if name has changed) Copy of a document with the former address Copy of Proof of Claim or other documents from the Bankruptcy case file *If original claimant is deceased, appropriate documentation to establish that the person executing the request for funds is authorized to act on behalf of the decedent's estate, such as certified copies of probate documents, including a copy of the death certificate and appointment of executor. Company: *W-9 Company's letterhead *Corporate Seal if the claimant is a corporation *Company business card or other corporate identification of claimant's representative Incorporated or Formed documents with year, state, and federal tax ID number Copy of Proof of Claim or other documents from the Bankruptcy case file *If the claimant is a corporation, partnership or other entity named as the claimant, the person acting on behalf of the claimant should indicate that (s)he has reviewed all records of the claimant and state that no other request for the funds has been submitted by or at the request of the claimant. *Documentation which establishes that the person executing the request is authorized to do so must be attached or the request will be returned. *If the requesting party is a successor in interest to a previous corporate claimant, documentation must be attached to establish the legal right of the applicant to the accounts receivable of the original claimant corporation. Copies of all documents evidencing successor assignment must be appended to the request. The Application for Release of Unclaimed Funds must be completed in its entirety and a copy sent to the United States Attorney at: U.S. Attorney PO Box 208 Grand Rapids, MI 49501 1 American LegalNet, Inc. www.FormsWorkFlow.com REQUIRED ITEMS THAT MUST BE COMPLETED: Proof of Service, including the date of service, of a copy of the Application on the United States Attorney Affidavit or Sworn Statement that you are the actual creditor or legal owner of the Unclaimed Funds in the case and that you formerly occupied the address of record (state address as you remember it). Affidavit must include current address and telephone number of a person knowledgeable about the claim. The signature of the claimant on the Application and Affidavit must be signed under oath in the presence of a Notary Public and the Notary's signature and seal affixed to the documents. If the requesting party is an attorney or "funds locator" who has been retained by the claimant, a notarized "power of attorney" from an individual claimant or from a duly authorized representative for the corporation, partnership or other entity named as the claimant must be attached. Any document that establishes that the person executing the "power of attorney" is authorized to so act must be attached. If applicable, the corporate seal of the claimant must be affixed to the power of attorney. Proposed Order, complete with amount due to the claimant, and current name and address of claimant Completed W-9 Mail the original with original signatures to: U.S. Bankruptcy Court One Division Avenue North, Room 200 Grand Rapids, MI 49503 ALL CORRESPONDENCE MUST BE FILED WITH THE COURT CONVENTIONALLY (BY PAPER), AND WILL BE PROCESSED IN ORDER OF DATE RECEIVED. PLEASE ALLOW AT LEAST 8 WEEKS FOR PROCESSING. Application for Release of Unclaimed Funds (Claimant) Application for Release of Unclaimed Funds (Locator) All applications are subject to final approval by the U.S. Bankruptcy Judge. Falsification of an Application for Release of Unclaimed Funds is illegal and subject to fines, penalties, sanctions, and/or imprisonment pursuant to Title 18, United States Code. FOR THE COURT: Daniel M. LaVille, Clerk For questions, please call the Finance Department at 616-456-2263 2 American LegalNet, Inc. www.FormsWorkFlow.com United States Bankruptcy Court for the Western District of Michigan IN RE: Debtor(s) _____________________________________/ APPLICATION FOR RELEASE OF UNCLAIMED FUNDS IT APPEARING THAT a dividend check in the amount of $________________ was issued by the trustee to _____________________________________________________, claimant in the above-referenced case. IT ALSO APPEARING THAT said check was not negotiated by said payee and the trustee, pursuant to 11 U.S.C. Section 347(a), delivered the unclaimed funds to the Clerk, United States Bankruptcy Court. These funds are currently being held by the United States Treasury. IT ALSO APPEARING THAT this application includes a signed and notarized affidavit of claimant which states that the undersigned is the legal owner of such funds. IT ALSO APPEARING THAT the United States Attorney for the Western District of Michigan has been provided a copy of this application allowing 20 days from the date of service to file an objection to payment of these funds. A proof of service is made part of this application. THEREFORE, an application is made for an order directing the Clerk of Court to pay said unclaimed funds to the order of _______________________________________________, claimant, and mail said check to the following address: ______________________________________________________________________. Dated:________________ _________________________________________ Claimant Case No. Subscribed and Sworn Before Me this _____ day of _______________. SEAL My commission expires:_______________ ________________________________ Notary Public in and for the State of _______________ Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT OF CLAIMANT I, ___________________________, do hereby state that I am the claimant to the unclaimed funds referenced in this application and that I am, to the best of my knowledge, the legal owner of these funds. My mailing address and phone number are _______________________________________________________________________________ ____________________________________________________