Application For Payment Of Unclaimed Funds {3011-1}

FORM 3011-1 () UNITED STATES BANKRUPTCY COURTNORTHERN DISTRICT OF OKLAHOMAIN RE:,Debtor(s).Case No. Chapter APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS (223Applicant224) applies to this Court for entry ofan order directing the Clerk to remit the sum of $ due to (223Claimant224). 1.Full legal name of Claimant(If Claimant is an individual, skip toQuestion No. 5)2.Type of Entity (corporation, LLC,partnership)3.State of Incorporation/Organization4.Name and Title of AuthorizingOfficer or Representative5.Current Mailing Address6.Telephone Number7.SS# (last 4 digits only) or EIN # 8.Amount Being ClaimedApplicant represents that Applicant is authorized to submit this Application and is entitledto receive the requested funds based upon:(check the applicable box) GApplicant is the original creditor and owner of the funds as it appears on the recordsof this Court; GApplicant is the assignee of the original creditor222s claim to said funds, as evidencedin the attached documentation; GApplicant is the original creditor222s successor in interest, as evidenced in the attacheddocumentation; American LegalNet, Inc. www.FormsWorkFlow.com FORM 3011-1 () GApplicant is an attorney or 223funds locator,224 named in a special/limited power ofattorney, which document is attached hereto, that is valid under the laws of the Stateof Oklahoma, that empowers Applicant to collect the unclaimed funds describedabove on behalf of the Claimant. Applicant states that the Claimant is the:(check the applicable box)Goriginal creditor and owner of the claim;Goriginal creditor222s attorney with authorization to receive said funds;Gassignee of the original creditor222s claim to said funds;Gsuccessor in interest of the original creditor; orGpersonal representative of the original creditor222s estate.Attached to the Application is the 223Affidavit of Claimant.224 (The Affidavit of Claimant isrequired only if the Applicant is an attorney or funds locator.) Applicant completed all necessary information on the Affidavit of Claimant prior to providing such Affidavit to theClaimant for execution. (This is necessary to ensure that the alleged claimant, contacted bya funds locator, has sufficient information to verify that he/she/it is in fact entitled to thefunds that the attorney or 223funds locator224 is applying for on behalf of the Claimant.) This Application is submitted with the necessary documents to establish (1) Applicant222sauthority to collect the unclaimed funds on behalf of the Claimant and (2) the Claimant222s entitlementto the particular unclaimed funds. The Application was completed and submitted in accordancewith this Court222s Instructions for Filing an Application for Payment of Unclaimed Funds. Applicant declares under penalty of perjury that sufficient inquiry has been made todetermine that the above funds have not been previously paid, no other applications for payment ofsaid funds are pending, and no party other than Claimant is entitled to submit a request fordisbursement of the funds.Applicant certifies that a copy of this Application (and all attachments) was provided to theOffice of the United States Attorney, Northern District of Oklahoma, Attn: Civil Process Clerk, 110W.7th Street, Suite 300, Tulsa, Oklahoma 74119-1029, as evidenced by the Certificate of Serviceattached hereto.Applicant requests that the Court enter an Order directing payment of the unclaimed fundsdescribed above to the Applicant, or if the Applicant is not the Claimant, to the , in accordance with the documents submitted in support of the Application. 2 American LegalNet, Inc. www.FormsWorkFlow.com FORM 3011-1 () I hereby certify that the foregoing statements are true and correct to the best of my knowledgeand belief. Signature Block for an Individual (Signature block for an entity on next page)Dated: Signature of Individual ApplicantSS# (last 4 digits only): (of the Applicant)Street AddressCity/State/ZipTelephone (including area code)State of )) ss.County of )Before me, , a notary public for said state, on this day of, 20, personally appeared , known to be the identicalperson(s) who executed the within foregoing instrument, and acknowledged to me that he/sheexecuted the same as his/her free and voluntary act and deed for the uses and purposes therein setforth.[SEAL]Notary PublicMy commission expires: 3 American LegalNet, Inc. www.FormsWorkFlow.com FORM 3011-1 () Signature Block for an EntityDated: Name of Applicant (if not an individual)EIN #: By(of the Applicant) Print Name: Title: Street AddressCity/State/ZipTelephone (including area code)State of )) ss.County of )Before me, , a notary public in and for said state, on this dayof , 20, personally appeared , as [capacity, e.g. president, treasurer] who executed the within foregoing instrument on behalf of [name of entity], and acknowledged to me that he/she executed thesame as his/her free and voluntary act and deed on behalf of said [type ofentity, e.g. corporation, limited liability company, partnership] for the uses and purposes therein setforth.[SEAL]Notary PublicMy commission expires: 4 American LegalNet, Inc. www.FormsWorkFlow.com FORM 3011-1 () [FORM OF] CERTIFICATE OF SERVICEIn accordance with 28 U.S.C. 247 2042, the undersigned hereby certifies that on, a true and correct copy of the foregoing Application (and all attachments) wasmailed via first class mail, postage prepaid, to:United States AttorneyAttn: Civil Process Clerk110 West 7 Street, Suite 300thTulsa, Oklahoma 74119-1029Note: Pursuant to Local Bankruptcy Rule 3011-1(B), notice of the Application shall also be servedupon the following parties:1.Debtor and Debtor222s counsel, if any;2.Trustee for the above referenced bankruptcy case3.United States Trustee; and4.Original creditor and creditor222s counsel, if any, if the Claimant is not the originalcreditor in the case.SignaturePrint Name5 American LegalNet, Inc. www.FormsWorkFlow.com FORM 3011-1 () UNITED STATES BANKRUPTCY COURTNORTHERN DISTRICT OF OKLAHOMAIN RE:, Debtor(s).Case No. Chapter AFFIDAVIT OF CLAIMANT(for use when Applicant is an attorney or funds locator)I, , the undersigned claimant (or dulyauthorized representative for the claimant as identified in paragraph (2)), declare as follows:1.(Name and Address of Funds Locator)has been granted a power of attorney to submit an Application For Payment of Unclaimed Funds (orI am the duly authorized representative for claimant as indicated in the attached power of attorney)seeking payment of: (select one)9 claim number (if no claim was filed write 223scheduled224 in blankspace) for which the dividend of $ is due and owing to me or theentity I represent as claimant in the above referenced bankruptcy case; 9funds deposited in the name of the debtor in the amount of $.2.My name, position with company (if claimant is not an individual), address andtelephone number are as follows:3.Copies of all necessary documentation, including those which establish the chain ofownership of the original corporate creditor (e.g., documents relating to a sale of company, purchaseagreements and/or stipulation by prior and new owner as to right of ownership of funds) and whichsubstantiate claimant222s right to the funds, are attached. 4.I (or the business that I represent as claimant) have neither previously received thesefunds nor contracted with any other party other than the person named in item one above to recover6 American LegalNet, Inc. www.FormsWorkFlow.com FORM 3011-1 () these funds.I hereby certify that the foregoing statements are true and correct to the best of my knowledgeand belief.Signature of claimant or duly authorized representative of claimantDated:Print NameTitleEIN # of entity or last 4 digits of SS# of individual claimantSworn to and Subscribed before me on this day of , 20.[SEAL]Notary PublicIn and for the State of My Commission expires:7 American LegalNet, Inc. www.FormsWorkFlow.com FORM 3011-1 () Instructions For Filing An Application For Payment of Unclaimed FundsTo file an Application for Payment of Unclaimed Funds, you must:1.Submit a notarized Application for Payment of Unclaimed Funds substantially in the formprescribed by this Court. See Local Rule 3011-1.2.Include