UNITED STATES BANKRUPTCY COURT Southern District of New York --------------------------------------------------------------x In re: CASE NO. AFFIDAVIT FOR REIMBURSEMENT OF UNCLAIMED DIVIDEND --------------------------------------------------------------x STATE OF: ) ) Social Security No/(TIN): COUNTY OF: ) OF: (Name of Creditor) (Address) being duly sworn, deposes and says: That he/she is a creditor of the above named debtor. That was duly adjudged a debtor in the United States Bankruptcy (Name of Debtor) Court for the Southern District of New York. That said creditor duly filed his/her claim, which was thereafter duly allowed. 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 deponent. It is therefore requested that the Clerk of this Court pay to the (Name of Creditor) sum of $ . (Signature of Creditor) Sworn and subscribed to before me this day of (Affix Corporate Seal) Notary Public **PLEASE ATTACH COUNTY CLERK'S CERTIFICATE IF OTHER THAN A NEW YORK NOTARY** ***PLEASE FORWARD TO ATTENTION OF FINANCIAL DEPARTMENT*** American LegalNet, Inc. www.FormsWorkFlow.com