NDOH Unclaimed Funds Petition (06/12) UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF OHIO In re: Debtors ) ) ) ) ) ) Case No. Chapter Judge PETITION FOR UNCLAIMED FUNDS AND ORDER THEREON1 ___________________, the Petitioner, under penalty of perjury, declares that the following statements and information are true and correct: 1. Identification of Claimant. The Claimant's current name, address, and telephone number are: Name: Address: Telephone Number: 1 For purposes of this Petition and the attached Exhibit A, the following terms apply: · "Petitioner" means either the Claimant or the Authorized Representative, or an attorney at law representing the Claimant or Authorized Representative. · "Claimant" means either (a) a party in the above-captioned case who was due to receive a distribution of funds from the estate of the Debtor, but which funds were instead deposited as unclaimed funds with the Court, or; (b) a person or entity that gained the rights of ownership of the original owner's claim. · "Authorized Representative" means a person or entity given written authorization by the Claimant to file this Petition on behalf of the Claimant, or a person or entity serving as a duly authorized representative of the estate of a Claimant who is deceased. This includes but is not limited to an employee of the Claimant, a funds locator service, and an attorney-in-fact. American LegalNet, Inc. www.FormsWorkFlow.com 2. Amount of Distribution. The Claimant was due to receive a distribution from the estate of the Debtor in the above-captioned case in the amount of $__________. The Claimant's Tax ID/Social Security Number and other required documentation are submitted separately with Exhibit A, and will be docketed as private docket events. Evidence of Funds Due. The funds due Claimant were deposited with the Court pursuant to 11 U.S.C. § 347. As evidence thereof, the following document is appended to the Petition (check applicable box): 3. 4. a copy of the Unclaimed Funds Search web page; a copy of the court order depositing the funds into the Treasury/Registry as unclaimed; a copy of the receipt and attached list of parties entitled to the unclaimed funds; other supporting documentation (please describe): __________________ __________________________________________________________. Legal Status of Petitioner. The following checked statement applies: Petitioner is the Claimant. Petitioner is an attorney at law representing the Claimant. Petitioner is the Authorized Representative of the Claimant. Petitioner is an attorney at law representing the Authorized Representative of the Claimant. The above subparagraphs do not apply, but Petitioner is entitled to payment of such monies because (state basis for claim): __________________________________________________________ __________________________________________________________ 5. Authorized Representative of Claimant. If the Petitioner is the Authorized Representative of the Claimant, or an attorney at law representing the Authorized Representative of the Claimant, append to the Petition a notarized, original power of attorney signed by the Claimant on whose behalf the representative is acting. 2 American LegalNet, Inc. www.FormsWorkFlow.com 6. Status of Successor Claimant. If the current Claimant is not the original holder of the claim, the following requirements apply: (a) Successor Business. If Claimant is a Successor Business Claimant, check this box G and append to the Petition the following documents: # a notarized power of attorney signed by an officer of the successor business; # a statement of the signing officer's authority; and # documentation establishing chain of ownership from the Business Claimant. Transferred Claim. If Claimant is a Successor Claimant holding a transferred (assigned) claim, check this box G and append to the Petition documentation evidencing the transfer of claim. Decedent's Estate. If the owner of record is deceased and the Claimant is the decedent's estate, check this box G and append to the Petition certified copies of probate documents establishing the representative's right to act on behalf of the decedent's estate. (b) (c) 7. Verification of Claim. Upon sufficient inquiry, and upon Petitioner's information and belief, this claim has not been previously paid, no other petitions or requests for payment are pending, and there are no other parties other than Claimant entitled to these funds. False Statements. Petitioner understands that pursuant to 18 U.S.C. § 152, a fine or imprisonment, or both, may be imposed if Petitioner has knowingly and fraudulently made any false statements in this document. Exhibit A. Petitioner certifies that the required proofs of identification attached to Exhibit A are legitimate and proper. Service. Petitioner has served a copy of the Petition for Unclaimed Funds and Order Thereon, Exhibit A, and all attached documents by regular U.S. Mail this ____ day of _______________, ______ to the United States Attorney for the Northern District of Ohio, Carl B. Stokes United States Courthouse, 801 West Superior Avenue, Suite 400, Cleveland, Ohio 44113. The United States Attorney is allowed 14 days from the date of service to file an objection to payment of these funds. 8. 9. 10. WHEREFORE, pursuant to 11 U.S.C. § 347, 28 U.S.C. § 2042, and Local Bankruptcy Rule 3011-1, Petitioner requests that the Court issue an Order directing payment to the Claimant in the amount set forth in section 2, above, and that payment be forwarded to the Petitioner. 3 American LegalNet, Inc. www.FormsWorkFlow.com Under penalty of perjury, I, the Claimant, or the Authorized Representative of the Claimant, certify that: 1. The information contained herein is true and correct to the best of my knowledge, information, and belief; 2. The Tax ID/Social Security Number on Exhibit A is correct, and; 3. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been 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, and; 4. I am (a) an individual who is a U.S. citizen or U.S. resident alien, or (b) a partnership, corporation, company, or association created or organized in the United States or under the laws of the United States. _____________________________________________ (Corpor