Identification Form For Unclaimed Dividends (Individual) {LF-3011-1.2}

R.I. Bankr. Form 3011-1.2 UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF RHODE ISLAND 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 ensure payment to the proper party, 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 a creditor/debtor in the above-named proceeding and request payment of my unclaimed dividend/refund check. The below information must be fully completed and match the former address on file with the Clerk's office. Failure to complete this information will cause the petition and this form to be considered defective and stricken. Old Address Current Address Driver's license No. Social Security Number , State (Signature) Subscribed and sworn to before me in This (State) (Notary Public) Day of . (City/Town) American LegalNet, Inc. www.FormsWorkFlow.com