Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Loading PDF...
Tags:
WAW 118.FI (1/12/2010)Application for Payment of Unclaimed Funds 226 Page 1 of 2 UNITED STATES BANKRUPTCY COURTWESTERN DISTRICT OF WASHINGTONIn re:Case Number:Debtor(s).Petition for Paymentof Unclaimed Funds 1.I am petitioning to receive funds in the total amount of $ , which amount was paid into the Court on [date(s)] by the case trustee as unclaimed funds on behalf of the following creditor/debtor:Name:Address: Last four digits of SS# or Tax ID#: 2.I believe I am entitled to receive the requested funds based upon the following [check the statement(s) that apply]:Ga. I am 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, including a current driver222s license and social security card (if an individual).Gb.I am the attorney in fact for the creditor/debtor named in paragraph 1, with authority to receive such funds,and am authorized by the attached notarized, original, Power of Attorney to file this application on the behalfof the creditor/debtor.Gc.I am the assignee or successor-in-interest of the creditor/debtor named in paragraph 1, or the assignee222s orsuccessor-in-interest222s representative, as evidenced by the attached documents establishing chain of ownershipand/or assignment.Gd.I am a duly authorized corporate officer (if a corporation) or a general partner (if a partnership) and arepresentative of the creditor/debtor named in paragraph 1, as demonstrated by the attached documentation,including, if applicable, the corporate seal.Ge.I am the representative of the estate of the deceased creditor/debtor named in paragraph 1, as evidenced by theattached certified copies of death certificate and other appropriate probate documents which substantiate myright to act on behalf of the decedent222s estate.Gf.Subparagraphs (a) through (e) above do not apply. As evidenced by the attached documents, I am entitledto such monies because: 3.I have no knowledge that any other party may be entitled to these funds and I am not aware of any dispute regarding thesefunds.4.Pursuant to 28 U.S.C. 247 2042, on [date], I mailed a copy of this completed application (with allsupporting documentation) to:United States Attorney, 700 Stewart St., Ste. 5220, Seattle WA 98101-1271. American LegalNet, Inc. www.FormsWorkFlow.com WAW 118.FI (1/12/2010)Application for Payment of Unclaimed Funds 226 Page 2 of 2 I understand that, pursuant to 18 U.S.C. 247 152, I shall be fined not more than $5,000, or imprisoned not more than fiveyears, or both, if I have knowingly and fraudulently made any false statements in this document or the accompanyingsupporting documents. I further understand that any indications of fraud detected by the Court will be turned over to theU. S. Attorney for possible prosecution.I declare (or certify, or verify, or state) under penalty of perjury under the laws of the United States of America,that the foregoing statements and information are true and correct.Dated: Petitioner222s Signature Petitioner222s Name Address Telephone Number( ) NOTARY: On this day, , I certify that I know or have satisfactory evidence that (insert name and title ofsigner) is the personwho appeared before me, and said person acknowledged that (he/she) signed this instrument and acknowledged it to be(his/her) free and voluntary act for the uses and purposes mentioned in the instrument. Notary Public(SEAL)My commission expires State of Residing at . American LegalNet, Inc. www.FormsWorkFlow.com AO 213(Rev. 0)ADMINISTRATIVEOFFICE OF THE UNITEDSTATESCOURTSAccounting DivisionVENDOR INFORMATION/TIN CERTIFICATIONMandatory Information that MUST be provided before submissionEx-AO EmployeeSAM Vendor(Formerly CCR)(No TIN Certification Required)Vendor AddressOther Address (If different from Vendor Address)Select all that apply Order Remit 1099Select all that apply Order Remit 1099Name:Address:Business Name:(if different from above)City:Address 1:State:Zip Code:Address 2:Phone #:City:Description:(If needed)State:Zip Code:Phone #:E-mail:Taxpayer Identification #:(TIN, SS, or EIN number)DUNS #Financial InformationBank Name:Routing # (this nine digit number appears on yourchecks, but do not include individual check numbers):City:Account #:State:Zip Code:Type of Account: (select one) Checking SavingsType of Organization for 1099 reporting: sole proprietorship; partnership; corporate entity (not tax-exempt); corporate entity (tax-exempt); health care provider; other: government entity (write in either federal, state orlocal)Taxpayer Identification Number CertificationUnder penalties of perjury, I certify that: 1.The Taxpayer Identification Number listed in the Vendor Address area above is the correct number assignedto me, and2.I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have notbeen 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, and3.I am a U.S. citizen or other U.S. person (defined below).You must select this check box if you have been notified by the IRS that you are currently subject to backup withholding becauseyou have failed to report all interest and dividends on your tax return. If you make a false statement with no reasonable basis thatresults in no backup withholdings, you are subject to a $500 penalty. Willfully falsifying certifications or affirmations on thisform may subject you to criminal penalties including fines and/or imprisonment.Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com AO 213(Rev. 0)Definitions:"Taxpayer Identification (TIN, SS, or EIN number)" is the number required by the Internal Revenue Service (IRS) to be used in reporting income tax and other returns. The TIN may be either a social security number (SSN) or an employer identification number (EIN)."U.S. person" means:!An individual who is a U.S. citizen or U.S. resident alien,!A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States.The TIN, as well as the information above is required in order to comply with debt collection requirements of 31 U.S.C. 247247 7701(c) and3325(d) , reporting requirements of 26 U.S.C. 247247 6041 and6041A , and implementing regulations issued by the IRS. Failure orrefusal to furnish this information may result in 28 percent backup withholding on any payments otherwise due under any awardedcontract or purchase order.The TIN may be used by the government to collect and report on any delinquent amounts arising out of the vendor's relationship withthe government (31 U.S.C. 247 7701(c)(3)) . The TIN provided may be matched with IRS records to verify its accuracy.Complete this section only if a TIN was not provided on page one, and select closest reason why not:The vendor is a nonresident alien, foreign corporation or foreign partnership that does not have income effectivelyconnected with the conduct of a trade or business in the United States and does not have an office or place of businessor a fiscal paying agent in the United States; The vendor is an agency or instrumentality of a foreign government;Additional information required for vendors used for procurement(purchase orders, contracts, etc.)Indicate which, if any, of the following categories are applicable. These categories require that the vendor is 51% owned and themanagement and daily operations are controlled by one or more members of the selected socio-economic group: Women Owned BusinessNot Applicable Minority Owned Business (If yes, select one of the owner's race/ethnicity selections from below): Asian-Pacific American Black AmericanSubcontinent Asian (Asian-Indian)American Hispanic American Native American Other:Date:Vendor222s signatureFor Agency Use OnlyThe vendor name and DUNS number is all that is required for registered System for Award Management (SAM) vendors (formerlyCCR). (Check www.sam.gov for registration status.) Do not use this form for purchase card merchants. Mark Boxes that apply:Add