Free BTXN127 - Unclaimed Funds - Application and Instructions - Texas

BTXN 127 (rev. 4/04)

UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF TEXAS

In Re:

Debtor(s)

§ § § § § §

Case No.:

APPLICATION FOR PAYMENT OF DIVIDEND UNCLAIMED FUNDS Comes now the undersigned, to make application for an order directing payment of unclaimed funds now on deposit in the Treasury of the United States. Claimant is a creditor debtor (check one) in the above captioned bankruptcy case and on whose behalf these funds were deposited.

Name of Claimant Name of Business Entity Title of Officer/Representative (if claimant is a business entity) Mailing Address City State Telephone Number: Home ( ) Work ( SS# Tax ID# (for all business entities) Amount Being Claimed

Zip )

I, ,do hereby state under penalty of perjury that I am legally entitled to claim these funds for whom the unclaimed funds were deposited into the treasury in the above referenced bankruptcy case. I certify to the best of my knowledge that all information submitted in support of this claim is true and correct.

Date Claimant Signature Subscribed and Sworn to Before Me this day of Co-Claimant Signature .

Notary Public In and for the State of My commission expires

Instructions for filing the Application for Payment of Unclaimed Funds
To file an application for payment of unclaimed funds, you must: 1. Submit a notarized Application for Payment of Unclaimed Funds. a. If the funds were deposited for joint claimants, both must sign the application b. The applicant must have legal standing to make the claim 2. Include legible copies of supporting documents establishing the final address of record at time of the bankruptcy case (a copy of proof of claim, correspondence from the court, tax forms, telephone or water bill). 3. If claiming on behalf of a deceased party, please include a copy of: a. Active estate 1. A death certificate 2. Letter designating an executor for the estate b. Inactive estate 1. A death certificate 2. Copy of the will 4. Photo identification issued by a government agency (copy of current driver's license or passport for each claimant). 5. If the original business entity claimant changed as a result of a merger, buyout or name change, please include supporting documents which substantiate your interest in the claim (documents from the Secretary of State in which claimant is incorporated). 6. Active corporate entities must submit: a. Current franchise tax corporate status in state of incorporation b. A current list of officers and directors c. Copy of Articles of Incorporation d. An imprint of the corporate seal e. Business card reflecting claimants' name, officer or representative's name and title attached to company letterhead stationery Inactive corporate entities must submit: a. Current franchise tax corporate status in state of incorporation b. A final list of officers and directors c. Copy of Articles of Incorporation d. Articles of Dissolution e. Date and list of final distribution of assets f. Final income tax return Sole proprietorship entity must submit: a. Appropriate federal income tax return b. Document showing business address at the time of the bankruptcy case (copy of invoice, a sales tax permit, business license)

Partnership entities must submit: a. Federal income tax return including schedule K-1 for all partners b. Written documentation from all partners authorizing the representative to claim the funds on their behalf 7. Mail the original plus two copies of the application and three sets of attachments to the following address: U.S. Bankruptcy Court Financial Section 1100 Commerce St., RM 1254 Dallas, TX 75242 8. The court will serve the U.S. Attorney with a copy of the application pursuant to 28 U.S.C. §2042. If no objection is filed within 20 days from the date of notice, the proper order and voucher will be executed to pay these funds. 9. Applications received which do not comply with the above requirements will be returned to the applicant.