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Affidavit For Reimbursement Of Unclaimed Dividend - New York
| Affidavit For Reimbursement Of Unclaimed Dividend Form. This is a New York form and can be used in Southern District Bankruptcy Court Federal . |
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UNITED STATES BANKRUPTCY COURT Southern District of New York --------------------------------------------------------------x In re: CASE NO. AFFIDAVIT FOR REIMBURSEMENT OF UNCLAIMED DIVIDEND --------------------------------------------------------------x STATE OF: COUNTY OF: ) ) ) Social Security No/(TIN):_______________________________ _____________________________________________________ OF____________________________________________________________ (Name of Creditor) (Address) ____________________________________________________________________________________________ __ being duly sworn, deposes and says: That he/she is a creditor of the above named debtor. That_______________________________________________________was duly adjudged a debtor (Name of Debtor) in the United States Bankruptcy Court for the Southern District of New York. That said creditor duly filed his/her claim, which was thereafter duly allowed. Dividends amounting to the sum of $_________________________remain unpaid. That the said claim has not been sold or assigned, and that it is still the property of deponent. It is therefore requested that the Clerk of this Court pay to_________________________ ______________________________________________ the sum of $______________________________. (Name of Creditor) ____________________________________________ (Signature of Creditor) Sworn and subscribed to before me this day of Affix Corporate Seal ________________________________ Notary Public **PLEASE ATTACH COUNTY CLERK'S CERTIFICATE IF OTHER THAN A NEW YORK NOTARY** ***PLEASE FORWARD TO ATTENTION OF FINANCIAL DEPARTMENT*** American LegalNet, Inc. www.FormsWorkFlow.com
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