MOW 3011-1.1 (10/2014) UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF MISSOURI In Re: ) ) Case No. Debtor(s) ) MOTION FOR PAYMENT OF UNCLAIMED FUNDS FROM COURT REGISTRY Comes now (movant's name, address, telephone number:) represented by , requests that the court enter an Order for Payment of Unclaimed Funds, and in support of the motion, states: A check in the amount of $ belonging to (name of original creditor/claimant) was tendered to the Clerk of Bankruptcy Court by the case trustee as unclaimed funds. The amount stated is being held in the Treasury of the United States as unclaimed funds. Movant is entitled to receive the requested funds based upon (check all that apply): Movant is the owner of said funds being the owner appearing on the records of this Court. Movant is the assignee of the owner of the claim to said funds, as evidenced in the attached Affidavit or Assignment or Right. Movant is the owner's successor in interest, as evidenced in the attached Affidavit and/or other identifying documents. Movant is the personal representative of the owner's estate, as evidenced in the attached Affidavit and/or other identifying documents. Movant is named in a LIMITED POWER OF ATTORNEY by (grantor) , as evidenced in the attached Power of Attorney document that empowers the movant to collect the unclaimed funds described above on behalf of the grantor: As the owner of the claim. As the owner's attorney at law, with authorization to receive said funds. As the assignee of the owner's claim to said funds. As the owner's successor in interest. As the personal representative of the owner222s estate. Other (describe) The following documents are submitted, as proof of the movant's identity and status as the owner of claim of entitlement: Power of Attorney Formal Assignment Letter of Appointment Court Order Completed IRS Form W9 or AO Form 213 (Vendor / TIN Certification) (Required) Other (describe) American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, movant requests the Court to enter an Order Directing Payment of the Unclaimed Funds described above to , at the following address in accordance with the documents submitted in support of this motion. The movant declares under penalty of perjury that the foregoing is true and correct. The movant understands that they may be subject to a fine or imprisonment, or both, if they have knowingly and fraudulently made any false statements in this document. Date: Signature Name Title Address SUBSCRIBED AND SWORN to before me this day of , 20. Signature: Notary My commission expires: CERTIFICATE OF SERVICE I, , certify that the Motion for Payment of Unclaimed Funds was either electronically served or served via the U.S. Post Office on the day of , 20, upon the following parties: U.S. Attorney for the Western District of Missouri 400 E. 9th St., Rm. 5510 Kansas City, MO 64106 U.S. Trustee for the Western District of Missouri (will receive automatic e-mail notice) Case Trustee (will receive automatic e-mail notice) Debtor222s Attorney (will receive automatic e-mail notice) Debtor (if not represented) Any other party to this motion Signature Name Address Telephone E-Mail Instructions: File as a separate document ECF Event: Bankruptcy>Motions/Applications/Requests>Pay Funds out of the Court Registry American LegalNet, Inc. www.FormsWorkFlow.com