UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF WASHINGTON In re: Case Number: Debtor(s). Petition for Payment of Unclaimed Funds and Order Thereon , which was tendered to the Clerk of the above-entitled 1. I am petitioning to receive the total amount of $ [date(s)] by the case trustee as unclaimed funds on behalf of Court on [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 issue based upon the following [check the statement(s) that apply]: G a. The applicant, whose Tax ID is , 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. G b. The applicant is the attorney in fact for the creditor/debtor named in paragraph 1, with authority to receive such funds, or is authorized by the attached notarized, original Power of Attorney to file this application on the . behalf of the creditor/debtor, whose Tax ID is G c. The applicant, whose Tax ID is , is the assignee or successor-in-interest of the creditor/debtor named in paragraph 1, or the assignee’s or successor-in-interest’s representative, as evidenced by the attached documents establishing chain of ownership and/or assignment. G d. The 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, whose Tax ID is G e. The applicant, whose Tax ID is , 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 which substantiate applicant’s right to act on behalf of the decedent’s estate. G f. Subparagraphs (a) through (e) above do not apply. As evidenced by the attached documents, the applicant is entitled to such monies because: 3. I understand that, pursuant to 18 U.S.C. § 152, I shall 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 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. 4. Pursuant to 28 U.S.C. § 2042, on [date], a copy of this completed application (with all supporting documentation) was mailed to: United States Attorney, 700 Stewart St., Ste. 5220, Seattle WA 98101-1271. WAW 118.FI (1/1/06) Application for Payment of Unclaimed Funds – Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com 5. 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: Applicant’s Signature Dated: Applicant’s Name Address Telephone Number On this day, ( ) , I certify that I know or have satisfactory evidence that (insert name and title of is the person signer) who 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 My commission expires (SEAL) State of Residing at . FOR COURT USE ONLY Approved as to Form: _______________ Financial Clerk IT IS ORDERED that the Clerk of the Bankruptcy Court shall disburse said amount to petitioner. DATED . . UNITED STATES BANKRUPTCY JUDGE WAW 118.FI (1/1/06) Application for Payment of Unclaimed Funds – Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com