UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF RHODE ISLAND - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -* In re: : : : Debtor(s) : : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -* R.I. LOCAL FORM 3011-1.1 (Rev. 7/15) BK No. Chapter PETITION FOR PAYMENT OF UNCLAIMED FUNDS I, the undersigned petitioner, under penalty of perjury under the laws of the United States of America, declare that the following statements and information are true and correct: 1. ____________________________ ("Petitioner") applies to this Court for entry of an order directing the Clerk to remit to Petitioner the sum of $______________ due to __________ ______________________________ ("Claimant"), whose address is ______________________ ___________________________________________________________________________. 2. [Please check and complete only ONE of the following subparagraphs, as applicable. Documentation must be attached to R.I. Bankr. Form 3011-1.2 or 3011-1.3, as applicable. Petitions submitted without the required supporting documentation attached to forms 3011-1.2 or 3011-1.3 will be considered defective and stricken. If filing this petition electronically, do not attach documentation to this petition when filing in cm/ecf]. Petitioner is the individual Claimant named in the Trustee's unclaimed funds check and states that no other application for this claim has been submitted by or at the request of this Claimant. Attach the following documentation to R.I. Bankr. Form 3011-1.2. A photocopy of photo identification of Claimant showing Claimant's signature [e.g., driver's license or passport]. If the name of the Claimant is different from the name of the original Claimant due to marriage, divorce, etc., appropriate documentation [e.g., certified copy of divorce decree, marriage license]. If Claimant is deceased, appropriate documentation to establish that the person executing the Petition is authorized to act on behalf of the decedent's estate [e.g., certified copies of all probate documents including a copy of the death certificate and appointment of executor]. American LegalNet, Inc. www.FormsWorkFlow.com Petitioner is a corporation, partnership or other entity named as the Claimant in the Trustee's unclaimed funds check Petitioner has reviewed all records of the Claimant and states that no other Petition for this claim has been submitted by or at the request of Claimaint. Documentation that establishes that the person executing the Petition is authorized to submit the Petition must be attached to R.I. Local Form 3011-1.3 or the Petition will be considered defective and stricken [e.g., board meeting minutes and articles of incorporation, current list of officers and directors, affidavit of secretary with copy of directors' resolution authorizing execution of the Petition or officer's certificate establishing that the corporate officer executing the Application is authorized to so act]. If the Petitioner is a successor in interest to a previous corporation, then documentation must be attached to R.I. Local Form 3011-1.3 to establish the legal right of the applicant to the accounts receivable of the claimant corporation [e.g., documents establishing the chain of ownership of the original corporate claimant, proof of sale of the company, new and prior owners, and a copy of the terms of any purchase agreement or stipulation by prior and new owners of right of ownership to unclaimed funds]. Copies of all documents evidencing assignment must be appended to R.I. Local Form 3011-1.3. Petitioner is an attorney or a "funds locator" who has been retained by Claimant. Attach the following documentation to R.I. Local Form 3011-1.2 or 3011-1.3, as applicable: An original, notarized "power of attorney" from an individual Claimant or from the duly authorized representative for the corporation, partnership or other entity named as the Claimant. Documentation that establishes that the person executing the "power of attorney" is authorized to so act [e.g., affidavit of secretary with copy of directors' resolution authorizing use of locator service or officer's certificate establishing that the corporate officer executing the "power of attorney" is authorized to so act]. 3. Petitioner has made sufficient inquiry and has no knowledge that this claim has been previously paid, that any other petition for this claim is currently pending before this Court, or that any party other than the Petitioner is entitled to submit a petition for the payment of this claim. 4. Applicant has provided notice to the United States Attorney for the District of Rhode Island of this Petition pursuant to 29 U.S.C. § 2042 and a certificate of service has been filed. 2 American LegalNet, Inc. www.FormsWorkFlow.com 5. I understand that, pursuant to 18 U.S.C. § 152, I will be fined not more than $5,000, or imprisoned not more than five years, or both, if I have knowingly and fraudulently made any false statements in this document. [Individual] Dated: ________________________ ______________________________ Signature of Individual Petitioner ______________________________ Street Address ______________________________ City and State ______________________________ Telephone (including area code) [Entity] Dated: ________________________ ______________________________ Name of Petitioner [if not an individual] By:___________________________ (Name of authorized Representative and Capacity/Title) ______________________________ Street Address ______________________________ City and State ______________________________ Telephone (including area code) NOTICE OF RESPONSE TIME Within twenty-one (21) days after service as evidenced by the certification, and an additional three (3) days pursuant to Fed. R. Bankr. P. 9006(f) if you were served by mail, any party against whom this paper has been served, or any other party to the action who objects to the relief sought herein, shall serve and file and objection or other appropriate response to this paper with the Bankruptcy Court Clerk's Office, 380 Westminster Street, 6th Floor, Providence, RI 02903, (401) 626-3100. CERTIFICATE OF SERVICE The petitioner mailed a copy of this petition and all attachments to the Office of the United States Attorney for the District of Rhode Island at Fleet Center, 50 Kennedy Plaza, 8th Floor, Providence, RI 02903 on (date) _________________. ______________________________ 3 American LegalNet, Inc. www.FormsWorkFlow.com