UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF TEXAS In Re: ' ' ' ' Case No. ______________ Debtor(s). Application for Payment of Unclaimed Funds and Certificate of Service 1. I am making application to receive $___________, which was deposited as unclaimed funds on behalf of ____________________________________________________________ (name of original creditor/debtor). 2. Applicant is entitled to receive the requested funds, has made sufficient inquiry and has no knowledge that any other party may be entitled to, and is not aware of any dispute regarding the funds at issued based upon the following (check the statement(s) that apply): Q Q a. Applicant is the creditor/debtor named in paragraph 1, and the owner of the funds appearing on the records of this Court, as evidenced by the attached documents. Applicant is the attorney in fact for the creditor/debtor named in paragraph 1, with authority to receive such funds, or who is authorized by the attached original Power of Attorney to file this application on behalf of the creditor/debtor. Applicant is the assignee or successor-in-interest of the creditor/debtor named in paragraph 1, or the representative of the assignee or successor-in-interest, as evidenced by the attached documents establishing chain of ownership and/or assignment. Applicant is a duly authorized corporate officer (if a corporation) or a general partner (if a partnership) and a representative of the creditor/debtor named in paragraph 1. Applicant is the representative of the estate of the deceased creditor/debtor named in paragraph 1, as evidenced by the attached certified copies of death certificate and other appropriate probate documents substantiating applicant's right to act on behalf of the decedent's estate. None of the above apply. As evidenced by the attached documents, applicant is entitled to these unclaimed funds because: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ b. Q c. Q d. Q e. Q f. American LegalNet, Inc. www.FormsWorkFlow.com 3. I understand that pursuant to 18 U.S.C. ' 152, I could be fined no 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 or accompanying supporting documents. I further understand that any indications of fraud detected by the Court will be turned over to the U.S. Attorney for possible prosecution. I declare under penalty of perjury under the laws of the United States of America that the foregoing statements and information are true and correct. Applicant's Signature _________________________ Applicant's Name _________________________ Address _________________________ _________________________ Phone: (____) ___________________ 4. Dated:________________ Subscribed and sworn before me this ____day of ____________________________. ___________________________________ Notary Public State of ____________________________ My commission expires________________ Attachments: 1.______________________ 2.______________________ 3.______________________ 4.______________________ Certificate of Service I certify that on __________(date), a true and correct copy of this application for payment of unclaimed funds was served by first class United States Mail on the following: U.S. Attorney 1000 Louisiana, Suite 2300 Houston, TX 77002 U.S. Trustee 515 Rusk Ave., Ste.3516 Houston, TX 77002 _______________________________________________ Signature Other:____________________________ ____________________________ ____________________________ ____________________________ American LegalNet, Inc. www.FormsWorkFlow.com