1234567891011121314151617181920212223242526 Name, Address, Telephone No., Bar Number, Fax No. & E-mail addressUNITED STATES BANKRUPTCY COURT DISTRICT OF NEVADA* * * * * *In re:Debtor(s). ))))))))))BK- ChapterMOTION TO WITHDRAW MONEYUNDER 28 U.S.C. SECTION 2042Hearing Date:Hearing Time:There was a dividend check in the amount $ in the above- named case issued to . Said check having not beencashed by said payee, the Trustee, pursuant to 11 U.S.C. Section 347(a), delivered the unclaimed money tothe Clerk, US Bankruptcy Court.PLEASE CHECK THE PARAGRAPH THAT APPLIES: G Claimant is the creditor or debtor in whose behalf these moneys were deposited and is entitled to themoneys deposited. G Claimant is not the creditor but is entitled to payment of these moneys because (Please state the basisfor your claim to the moneys) NVB 7067 (1) American LegalNet, Inc. www.FormsWorkFlow.com 1234567891011121314151617181920212223242526 Please attach copies of any supporting documentation.1Date: Signature of Claimant or Attorney Printed Name Mailing Address 1 (i)If claimant is heir of deceased creditor, attach copies of death certificate and heirship order of court. (ii)If claimant is assignee of creditor, attach copy of assignment. (iii)If claimant is corporate successor of creditor, attach copies of all documents demonstrating such status. (iv)If claimant is agent of creditor for purposes of filing this application, attach a copy of the agencyagreement. (v)Attach other documents showing entitlement should none of the foregoing apply. 2 American LegalNet, Inc. www.FormsWorkFlow.com 1234567891011121314151617181920212223242526 Name, Address, Telephone No., Bar Number, Fax No. & E-mail addressUNITED STATES BANKRUPTCY COURT DISTRICT OF NEVADA* * * * * *In re:) BK-)Chapter)) AFFIDAVIT FOR REIMBURSEMENT ) OF UNCLAIMED FUNDS Debtor(s). ) )STATE OF: COUNTY OF: SOCIAL SECURITY NO/TAX ID: of (NAME OF CREDITOR/DEBTOR) (ADDRESS) (ADDRESS CONTINUED) (PHONE NUMBER) being duly sworn, deposes and says: That he/she is a creditor of the above-named bankrupt/debtor or is the debtor. That (Name of Debtor/Bankrupt) was duly adjudgeda debtor/bankrupt in the United States Bankruptcy Court for the District of Nevada. That said creditor dulyfiled his/her claim, which claim was thereafter duly allowed or is the debtor in the above named case.Dividends amounting to the sum of $ remain unpaid.That the said claim has not been sold or assigned, and that it is still the property of thedeponent. 3 American LegalNet, Inc. www.FormsWorkFlow.com 1234567891011121314151617181920212223242526 It is therefore requested that the Clerk of this Court pay to the sum of $ . (Signature) Sworn and subscribed to beforeme this day of (Notary Public)Seal4 American LegalNet, Inc. www.FormsWorkFlow.com 1234567891011121314151617181920212223242526 Name, Address, Telephone No., Bar Number, Fax No. & E-mail addressUNITED STATES BANKRUPTCY COURT DISTRICT OF NEVADA* * * * * *In re:Debtor(s). )))))))))BK- ChapterAFFIDAVIT OF SERVICENotice is hereby given to the court that on, the U.S. Attorney for the District of Nevada was advised, via United States Mail, of the 223Motion for Payment of Unclaimed Funds.224Date: Respectfully submitted, American LegalNet, Inc. www.FormsWorkFlow.com AO 213 (Rev. 0) ADMINISTRATIVE OFFICE OF THE UNITED STATES COURTSAccounting DivisionVENDOR INFORMATION/TIN CERTIFICATIONMandatory Information that MUST be provided before submissionEx-AO EmployeeSAM Vendor(Formerly CCR)(No TIN Certification Required)Vendor AddressOther Address (If different from Vendor Address)Select all that apply Order Remit 1099Select all that apply Order Remit 1099Name:Address:Business Name:(if different from above)City:Address 1:State:Zip Code:Address 2:Phone #:City:Description: (If needed)State:Zip Code:Phone #:E-mail: Taxpayer Identification #:(TIN, SS, or EIN number)DUNS # Financial Information Bank Name:Routing # (this nine digit number appears on yourchecks, but do not include individual check numbers):City:Account #:State:Zip Code:Type of Account: (select one) Checking SavingsType of Organization for 1099 reporting: sole proprietorship; partnership; corporate entity (not tax-exempt); corporate entity (tax-exempt); health care provider; other: government entity (write in either federal, state or local) Taxpayer Identification Number CertificationUnder penalties of perjury, I certify that: 1.The Taxpayer Identification Number listed in the Vendor Address area above is the correct number assignedto me, and2.I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have notbeen notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest and dividends, or (c) the IRS has notified me that I am no longer subject to the backup withholding, and3.I am a U.S. citizen or other U.S. person (defined below).You must select this check box if you have been notified by the IRS that you are currently subject to backup withholding becauseyou have failed to report all interest and dividends on your tax return. If you make a false statement with no reasonable basis thatresults in no backup withholdings, you are subject to a $500 penalty. Willfully falsifying certifications or affirmations on thisform may subject you to criminal penalties including fines and/or imprisonment.Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com AO 213 (Rev. 0) Definitions:"Taxpayer Identification (TIN, SS, or EIN number)" is the number required by the Internal Revenue Service (IRS) to be used in reporting income tax and other returns. The TIN may be either a social security number (SSN) or an employer identification number (EIN)."U.S. person" means:!An individual who is a U.S. citizen or U.S. resident alien,!A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States.The TIN, as well as the information above is required in order to comply with debt collection requirements of 31 U.S.C. 247247 7701(c) and 3325(d) , reporting requirements of 26 U.S.C. 247247 6041 and 6041A , and implementing regulations issued by the IRS. Failure orrefusal to furnish this information may result in 28 percent backup withholding on any payments otherwise due under any awardedcontract or purchase order.The TIN may be used by the government to collect and report on any delinquent amounts arising out of the vendor's relationship withthe government (31 U.S.C. 247 7701(c)(3)) . The TIN provided may be matched with IRS records to verify its accuracy.Complete this section only if a TIN was not provided on page one, and select closest reason why not:The vendor is a nonresident alien, foreign corporation or foreign partnership that does not have income effectivelyconnected with the conduct of a trade or business in the United States and does not have an office or place of businessor a fiscal paying agent in the United States; The vendor is an agency or instrumentality of a foreign government;Additional information required for vendors used for procurement(purchase orders, contracts, etc.)Indicate which, if any, of the following categories are applicable. These categories require that the vendor is 51% owned and themanagement and daily operations are controlled by one or more members of the selected socio-economic group: Women Owned BusinessNot Applicable Minority Owned Business (If yes, select one of the owner's race/ethnicity selections from below): Asian-Pacific American Black AmericanSubcontinent Asian (Asian-Indian)American Hispanic American Native American Other:Date:Vendor222s signatureFor Agency Use OnlyThe vendor name and DUNS number is all that is required for registered System for Award Management (SAM) vendors (formerlyCCR). (Check www.sam.gov for registration status.) Do not use this form for purchase card merchants. Mark Boxes that apply:Addition ChangeVendor Code:(make entry only if change)Active InactiveVendor Type:The following information is optional for individuals whose name and telephone are already on the form:Contact Name:Telephone Number:Email:Identification of person mak