UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF NORTH CAROLINA IN RE: CASE NO.: MOTION TO RELEASE UNCLAIMED FUNDS 1. A dividend check in the amount of $ was issued by the trustee to , creditor in the above referenced case ("the creditor"). 2. The dividend check was not negotiated by the creditor. Therefore, the trustee, pursuant to 11 U.S.C. Section 347(a), delivered the unclaimed funds to the Clerk of the U. S. Bankruptcy Court for the Eastern District of North Carolina. The United States Treasury is currently holding these funds. The creditor's current address, and social security or tax identification number are: Name: Address: Social Security/ Tax ID# 3. 4. The creditor did not receive the dividend check for the following reason: 5. I am the creditor named in paragraph #1. To the best of my knowledge, no other party is entitled to these funds. Proof of my identity is attached (ex. copy of drivers license, passport or other photo identification). I hereby certify that a copy of the foregoing Motion to Release Unclaimed Funds was served upon the United States Attorney for the Eastern District of North Carolina, 310 New Bern Avenue, Suite 800, Federal Building, Raleigh, NC 27601. Wherefore, the creditor requests that the court issue an order directing the clerk to make disbursement of said unclaimed funds for the benefit of the creditor. 6. Dated: Creditor's Signature REV.08/12 American LegalNet, Inc. www.FormsWorkFlow.com