To: Subject: Applicant for Withdrawal of Unclaimed Funds Procedure for Applying for Payment of Unclaimed Funds The following procedures must be followed in order to apply for the payment of unclaimed funds: - Prepare an AApplication for Order Directing Payment of Unclaimed Funds@ and make sure to sign it. (example attached) - Complete the attached AAffidavit of Creditor@ form and have it notarized. Every application must include an AAffidavit of Creditor.@ The notarization must be visible and the notary must personally sign the document. - If creditor is an individual, include a photocopy of your driver=s license or some other form of personal identification with photograph. - If creditor is a corporation, partnership, or other entity, include supporting documentation that the applicant is authorized to claim money on behalf of the corporation, partnership, or other entity. - Mail or deliver all of the original documents to the Court Clerk=s office at the following address: United States Bankruptcy Court Western District of Oklahoma Attn: Tony Sossamon 215 Dean A. McGee Avenue Oklahoma City, OK 73102 - Mail or deliver a copy of the completed AApplication for Order Directing Payment of Unclaimed Funds@ to the U.S. Attorney at the following address: United States Attorney Western District of Oklahoma 210 West Park Avenue, Suite 400 Oklahoma City, OK 73102 After submission of the application to the Clerk=s office, processing the request will require from two to six weeks. Upon completion, a check will be mailed to the applicant. If you have questions about filling out and submitting the required documents or any other questions about the procedures, please contact Tony Sossamon at (405) 609-5755. American LegalNet, Inc. www.FormsWorkFlow.com LOCAL FORM 5 UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF OKLAHOMA IN RE: Debtor(s) name, Debtor(s). ) ) ) ) ) Case No. ___-______-___ Chapter _____ APPLICATION FOR ORDER DIRECTING PAYMENT OF UNCLAIMED FUNDS TO CREDITOR/CLAIMANT A dividend/refund check in the above-named case issued to the payee, _______________ __________________________________________, in the amount of $________, was not cashed by said payee, and, pursuant to 11 U.S.C. § 347(a) of the Bankruptcy Code, the trustee paid this unclaimed money to the Registry of the Clerk, United States Bankruptcy Court. The undersigned creditor/claimant has made sufficient inquiry and has no knowledge that this claim has been previously paid, that any other application for this claim is currently pending before this Court, or that any other party other than this Applicant is entitled to submit an application for this claim. Applicant has provided notice to the U.S. Attorney pursuant to 28 U.S.C. § 2042. THEREFORE, Application is hereby made for the Clerk, U.S. Bankruptcy Court, to pay this unclaimed money to (Name and address of payee (creditor/claimant) . _______________________________ Date ____________________________________ Signature of creditor/claimant American LegalNet, Inc. www.FormsWorkFlow.com _______________________________ Tax ID or last 4 numbers of SSN ___________________________________ Print name of creditor/claimant ___________________________________ Address of creditor/claimant I hereby certify by my signature above, that a copy of this Application was mailed on the _____ day of ______________, 20___, to the United States Attorney, 210 Park Avenue, Suite 400, Oklahoma City, OK 73102 and to the following: Panel Trustee Assistant United States Trustee Debtor Debtor's Attorney, if any Original Claimant, if different Original Claimant's Attorney, if discernible ___________________________________ Signature of creditor/claimant American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF OKLAHOMA IN RE: Debtor(s) name, Debtor(s). ) ) ) ) ) Case No. ___-______-___ Chapter _____ AFFIDAVIT OF CREDITOR/CLAIMANT State of ______________________ ) : ss County of ____________________ ) Tax ID or Last 4 numbers of SSN: ___________________________ I. ___________________________________, the undersigned creditor/claimant in the above referenced case, being first duly sworn upon oath, state as follows: 1. (Name and Address) has been granted a power of attorney by me to submit Application for Payment from Unclaimed Funds seeking payment of claim number ________, in the amount of $______________, due and owing to me as a creditor/claimant in the above-referenced bankruptcy case. 2. My name, position with the company (if applicable), address and telephone number are as follows: ___________________________________________ ___________________________________________ ___________________________________________ 3. If other than individual: Substantiate creditor's right to claim, including but not limited to, documents relating to sale of company, i.e., purchase agreements and/or stipulation by prior and new owner as to right of ownership of funds. Attach certified copies of all necessary documentation. American LegalNet, Inc. www.FormsWorkFlow.com 4. I (or the entity I represent) have neither previously received remittance for the claim nor have contracted with any other party other than the person named in Item 1 above to recover these funds. I certify that the foregoing statements are true and correct to the best of my knowledge and belief. DATED: _______________________ __________________________________ Creditor/Claimant Signature Subscribed and sworn to before me this ______ day of _________________, 20___. My commission expires: ______________________ (Seal) __________________________________ Notary Public American LegalNet, Inc. www.FormsWorkFlow.com