Identification Form For Unclaimed Funds (Corporate-Business)

UNITED STATES BANKRUPTCY COURT FOR THE SOUTHERN DISTRICT OF IOWA 110 E. Court Avenue, Ste 300 Des Moines, Iowa 50309 www.iasb.uscourts.gov In the Matter of: Case No. IDENTIFICATION FORM FOR UNCLAIMED FUNDS CORPORATE/BUSINESS I, _________________________________________, hereby state that I am the __________________________________, of ________________________________________ (Title) (Business Name) and I am authorized to request payment of the unclaimed funds referenced in the attached Motion. I am enclosing the attached document(s), including but not limited to corporate documents (if applicable) showing proof of ownership of funds through amendment (such as a name change), assignment, assumption, merger, and/or dissolution, and proper authority to act on behalf of the corporation (if applicable), that substantiate(s) my authorization. (CORPORATE SEAL) Signature: Name: Address: Telephone: ATTACH A PHOTOCOPY OF A BUSINESS CARD AND A GOVERNMENT ISSUED PHOTO IDENTIFICATION CARD (i.e. DRIVER'S LICENSE, ETC.) J:\Web\Forms\PDF Files\ID Corp Unclaimed Funds.pdf 6/25/13 American LegalNet, Inc. www.FormsWorkFlow.com