Application For Refund {15-F}

IN THE UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF PENNSYLVANIA In Re: Debtor : : : : : : : : : : : Bankruptcy No. Chapter Document No. Movant v. Respondent (if none, then "No Respondent") APPLICATION FOR REFUND I, the undersigned movant, under penalty of perjury under the laws of the United States of America, declare (or certify, verify or state) that the following statements and information are true and correct: 1. Please check and complete the applicable subparagraph below: A. 9 I am moving to receive the total amount of $______________, which is the sum of the overpayment of filing fee for the document filed in the above-named case on the date(s) of ___________________________ on behalf of the debtor(s). 9 I am moving to receive the total amount of $______________, which is the sum of the overpayment of filing fee for the document filed in the above-named case on the date(s) of ___________________________ on behalf of the creditor, __________________________________ . B. 2. Receipt No. _______, for the overpayment of filing fee, was issued on _______________ in the amount of $___________. Refund should be sent to the following complete name and address: 3. 4. I understand that, pursuant to 18 U.S.C. Section 152, I shall be fined not more than $5,000, or imprisoned not more than five (5) years, or both, if I have knowingly and fraudulently made any false statements in this document. I understand that it will take approximately 6 to 8 weeks to receive this refund. 5. Date Executed: ______________________ Movant's Signature: __________________________________________________________ Name of Movant (Please type or print): ___________________________________________ Complete Address of Movant (Please type or print): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Form #15-F American LegalNet, Inc. www.FormsWorkFlow.com IN THE UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF PENNSYLVANIA In Re: Debtor Movant v. Respondent (if none, then "No Respondent") : : : : : : : : : : : ORDER Bankruptcy No. Chapter Document No. AND NOW, this ________ day of _________________, 201____, upon consideration of the Application for Refund, the Clerk shall refund the filing fee in the amount of $______________, paid on ________________________ to ____________________________________________. _____________________________________ United States Bankruptcy Court Form #15-F American LegalNet, Inc. www.FormsWorkFlow.com