Corporate Or Business Indentification Form For Unclaimed Dividends {LF-3011-1.3}

R.I. Bankr. Form 3011-1.3 UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF RHODE ISLAND CORPORATE/BUSINESS IDENTIFICATION FORM FOR UNCLAIMED DIVIDENDS Case Name Case No. Amount of dividend/refund A dividend/refund check was previously issued in your name in accordance with an Order of this Court, however said check was not cashed and has been deposited with the United States Treasury Account. In order to insure payment to the proper party, please fill out the identification portion on this form and either electronically file (see LBR 3011-1), or mail the form to: U.S. Bankruptcy Court, 380 Westminster St., Providence, RI 02903, Attn: Financial Dept. Upon receipt of the completed document, your request for payment of unclaimed funds held by the Court will be processed. =============================================================== I, , hereby state that I am the (Title) of whose TIN# is , and that I am (Business Name) authorized to request payment of the above dividend. (Signature) Subscribe and sworn to before me in (City/Town) This (State) (Notary Public) Day of (Corporate Seal) , 20 . American LegalNet, Inc. www.FormsWorkFlow.com