Application For Payment Of Unclaimed Funds {BTXN 127}

BTXN 127 (rev. 1/14) UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF TEXAS In Re: Debtor(s) § § § § § § Case No.: APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS Comes now the undersigned, to make application for an order directing payment of unclaimed funds creditor debtor (check one) now on deposit in the Treasury of the United States. Claimant is a in the above captioned bankruptcy case and on whose behalf these funds were deposited. 1. Name of Claimant(s) Name and Title of Authorizing Officer or Representative (If Claimant is an individual, skip to Question No. 3) Current Mailing Address Telephone Number SS# (last 4 digits only) or EIN # Amount Being Claimed 2. 3. 4. 5. 6. I, ,do hereby state under penalty of perjury that I am legally entitled to claim these funds for whom the unclaimed funds were deposited into the treasury in the above referenced bankruptcy case. I certify to the best of my knowledge that all information submitted in support of this claim is true and correct. Date Claimant Signature Subscribed and Sworn to Before Me this day of Co-Claimant Signature . Notary Public In and for the State of My commission expires American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF SERVICE In accordance with 28 U.S.C. § 2042, the undersigned hereby certifies that on the date designated below, a true and correct copy of the foregoing application with all required attachments was mailed to: Office of the United States Attorney Attn: Unclaimed Funds 1100 Commerce Street, 3rd Floor Dallas, TX 75242 Date:________________________ ___________________________ Claimant's Signature American LegalNet, Inc. www.FormsWorkFlow.com Instructions for filing the Application for Payment of Unclaimed Funds The court will only disburse unclaimed funds to the rightful owner upon full proof of the right thereto. Therefore, the following forms and documentation are required: 1. An Application for Payment of Unclaimed Funds, include the case name and number. a. If the funds were deposited for joint claimants, both claimants must sign the application. b. The applicant must have legal standing to make the claim. When the owner of record is not the claimant, the signer or claimant requesting release of funds must show proper authority. Notice of Service to the US Attorney. (US Attorney's mailing address is on the form) Required supporting documentation: 1. A legible copy of a document with former address on it establishing proof of the address of record at the time of the bankruptcy case (a copy of proof of claim, correspondence from the court, tax forms, telephone or water bill, etc.). A photocopy of an official government identification card (i.e. Passport, Military ID, or valid and current driver's license) for each claimant. Form AO213 Vendor Information/TIN Certification. 2. 3. 2. 3. The following additional documentation is required: If the claimant(s) is represented by an attorney or a funds locator: 1. 2. 3. 4. Proof of identity of the owner of record. An original notarized Power of Attorney signed by the claimant on whose behalf the representative is acting. Proof of identity of the representative; and Documentation sufficient to establish the claimant's entitlement to the funds. (See above) If claiming on behalf of a deceased party: 1. 2. 3. Copy of the death certificate. Certified copies of probate documents establishing the representative's right to act on behalf of o the decedent's estate Proof of personal identity of the estate administrator. American LegalNet, Inc. www.FormsWorkFlow.com If the Claimant is a Corporation/Partnership: 1. 2. 3. 4. Application must be signed by an agent for and on behalf of the Corporation/Partnership. A statement of the signing agent's authority. Documentation establishing chain of ownership of the original corporate claimant. A photocopy of representative's identification credentials Purchased or assigned claims: 1. Documentation evidencing the transfer of claim or proof of the purchase/sale of assets. Mail the original application to the following address: U.S. Bankruptcy Court 1100 Commerce St., Room 1254 Dallas, TX 75242 Applications received which do not comply with the above requirements may be denied by the court. Claims could take up to 90 days to complete. Privacy note: Because documents filed with the court are available through the Internet, the court is committed to the protection of personal identification information. The individual applicant's driver's license number should be blacked out for privacy considerations. Also, all but the last four digits of the Social Security number should be blacked out for the same privacy reasons. Responsibility. The responsibility for redacting these personal identifiers rests solely with counsel and the parties. The bankruptcy clerk is not responsible for ensuring compliance. American LegalNet, Inc. www.FormsWorkFlow.com