UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF MISSOURI In Re: ) ) ) ) ) ) ) ) ) Case No. Chapter APPLICATION FOR PAYMENT FROM UNCLAIMED FUNDS Debtor(s) The undersigned, , applies to this Court 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 order of this Court as unclaimed funds for creditor Applicant further states that: 1. (Indicate one of the following items:) Applicant is the individual creditor named in the order depositing funds into the Court and states that no other application for this claim has been submitted by or at the request of this creditor. Applicant is the duly authorized representative for the business or corporation named as the creditor in the order depositing funds into the Court. 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 an attorney or a "funds locator" who has been retained by the creditor. Applicant has obtained an original "power of attorney" from the individual creditor or the duly authorized representative for the business or corporation named as the creditor in the order depositing funds into the Court. A Power of Attorney, conforming to the official Bankruptcy Form and an Affidavit of Creditor are attached and made a 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 in the order depositing funds into the Court. An original "power of attorney" conforming to the official Bankruptcy Form and/or other supporting documents, including probate documents which indicate applicant's entitlement to this claim are attached and made a part of this application. 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 . American LegalNet, Inc. www.FormsWorkFlow.com that any party other than the applicant is entitled to submit an application for this claim. 3. Applicant has provided notice to the United States Attorney pursuant to 28 U.S.C. Section 2042. Respectfully submitted this day of , 20 . Name of Creditor SS # (last 4 digits) Signature of Applicant Name and Title of Applicant Company Name _________________________________________ Street Address ________________________________________ City, State and Zip Code Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com