PROBATE COURT OF HAMILTON COUNTY, OHIO RALPH WINKLER, JUDGE IN THE MATTER OF CASE NO. APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS Now comes the amount of ($ , the recipient of check no. in ) which was a refund of prepaid but unearned court day of , , costs in the above captioned matter and makes application for payment of unclaimed funds. Applicant states that on the ($ ) was paid from the Court's escrow account into the county treasury as unclaimed funds for the benefit of the applicant in accordance with R.C. 2335.35. Applicant moves the Court to order the payment of said funds to applicant. Applicant's Signature Typed or Printed Name Address ( ) Phone Number (include area code) H.C. FORM 110.62 - APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS 11/01/04 American LegalNet, Inc. www.FormsWorkFlow.com