Affidavit For Reimbursement Of Unclaimed Dividends

1 Afdt 2 UNITED STATES BANKRUPTCY COURT 3 DISTRICT OF NEVADA 4 IN RE: ) ) 5 ) BK- DEBTOR ) 6 ) 7 AFFIDAVIT FOR REIMBURSEMENT OF UNCLAIMED DIVIDENDS 8 STATE OF: ) ) SOCIAL SECURITY NO: 9 COUNTY OF: ) 10 OF 11 (NAME OF CREDITOR/DEBTOR) (ADDRESS) 12 (PHONE NUMBER) being duly sworn, deposes and says: 13 That he/she is a creditor of the above-named 14 bankrupt/debtor or is the debtor. That 15 (Name of Debtor/Bankrupt) 16 was duly adjudged a debtor/bankrupt in the United States 17 Bankruptcy Court for the District of Nevada. That said creditor 18 duly filed his/her claim, which claim was thereafter duly allowed 19 or is the debtor in the above named case. 20 Dividends amounting to the sum of $ remain unpaid. 21 That the said claim has not been sold or assigned, and that 22 it is still the property of the deponent. 23 It is therefore requested that the Clerk of this Court pay 24 to the sum of $ . 25 26 (Signature) Sworn and subscribed to before 27 me this day of 28 (Notary Public)