1 Submitting Attorney (Utah State Bar No.) Address Telephone No. Facsimile No. (Optional) E-Mail Address (Recommended) Attorney for IN THE UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF UTAH In re: Debtor(s). Bankruptcy No. Chapter Hon. APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS AND NOTICE OF OBJECTION DEADLINE The undersigned, 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.(Claimant) applies to this Court, pursuant to 28 U.S.C.2472042 for entry of an order directing the Clerk of this Court to remit to Claimant the sum of$ due to Claimant. 2.(check applicable paragraph) GClaimant is the original claimant named in the trustee222s unclaimed funds report filed in this case; or GClaimant is the holder of a valid assignment of a claim listed in the trustee222s unclaimed funds report and appropriate documentation substantiating the assignment of the original claim [e.g. a notarized acknowledgment of American LegalNet, Inc. www.FormsWorkFlow.com 2 assignment] is attached hereto; or GThe original claimant listed in the trustee222s unclaimed funds report filed in this case is deceased, and Claimant is a person authorized to act on behalf of the estate of the original claimant and appropriate documentation substantiating Claimant222s authority [e.g., certified copies of all probate documents including a copy of the death certificate and appointment of executor] is attached. 3.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 party other than the Claimant is entitled to submit an application for the payment of this claim. 4.Claimant has provided notice to the United States Attorney for the District of Utah of this Application pursuant to 28 U.S.C. 247 2042 and a certificate of mailing is attached to this Application. 5.A photocopy of government issued photo identification of Claimant showing Claimant222s signature [e.g. driver222s license or passport] is attached. If name of the Applicant 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] is attached. 6.I understand that, pursuant to 18 U.S.C. 247247 152 and 3571, I will be fined not more than $500,000, or imprisoned not more than five years, or both, if I have knowingly and fraudulently made any false statements in this document. American LegalNet, Inc. www.FormsWorkFlow.com 3 The responsibility for redacting personal data identifiers rests solely with the filing party. NOTICE OF OBJECTION DEADLINE Any party in interest who objects to the relief sought in this Application must, within twenty-one (21) days of the mailing of this Application, serve and file an objection or other appropriate response to this Application with the Bankruptcy Court Clerk222s Office 350 South Main Street, 3rd Floor, Salt Lake City, UT 84101. Date Printed name of Claimant(s) Signature of Claimant(s) Street Address City and State Last Four Digits of SSN or full Tax ID Number if Claimant is a business Telephone and Email Address American LegalNet, Inc. www.FormsWorkFlow.com 4 STATE OF ) : ss. COUNTY OF ) The foregoing instrument was subscribed and sworn to and acknowledged before me This Day of , 20. My Commission Expires: (Notary Public) CERTIFICATE OF MAILING I hereby certify that on (date), I mailed a copy of this foregoing Application and all attachments to the following: Office of the United States Attorney District of Utah 185 South State Street, Suite 300 Salt Lake City, UT 84111 United States Trustee Ken Garff Building 405 South Main Street, Suite 300 Salt Lake City, UT 84111 Chapter Trustee (Name and address of case trustee) Debtor (Name and address of Debtor) Debtors222 Attorney (Name and address of Debtor222s Attorney) Original Claimant (Name and address of original claimant) Dated: (Claimant222s Signature) American LegalNet, Inc. www.FormsWorkFlow.com