UNITED STATES BANKRUPTCY COURT FOR THE SOUTHERN DISTRICT OF WEST VIRGINIA Case Name: ________________________________ Case Number ___________________ ________________________________ Chapter ______ TRUSTEE FUNDS SUBMISSION FORM _____ Attached is a check in the amount of $_________________ for deferred filing fees or other court costs as listed below: Adversary Case No. _________________ Adversary Case No. _________________ Other: ____________________________ $___________ $___________ $___________ _____ Attached is a check in the amount of $___________ for claims under $5.00, to be treated as unclaimed funds pursuant to Bankruptcy Rule 3010(a). Such check consists of funds due to the claimant(s) listed below. _____ Attached is a check which reflects unclaimed funds in the amount of $______________, due to returned checks and for checks not presented for payment within 90 days, etc. Such check consists of funds returned from the claimant(s) listed below. CLAIM NUMBER CLAIMANT (Name & address) SSN (last 4 digits only) or FEIN (all digits) _______ _______________________________ _______________________________ _______________________________ _____________ AMOUNT OF UNCLAIMED FUNDS $___________ _______ ________________________________ ________________________________ ________________________________ _____________ $___________ _______ _______________________________ _______________________________ _______________________________ _____________ $___________ _______ _______________________________ _______________________________ _______________________________ _____________ $___________ Dated: _____________ _______________________________ Trustee American LegalNet, Inc. www.FormsWorkFlow.com