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Affidavit Of Claimant (Sample And Form) LF-28 - Florida
| Affidavit Of Claimant (Sample And Form) Form. This is a Florida form and can be used in USBC Southern Federal . |
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UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF FLORIDA www.flsb.uscourts.gov In re: Case No. Chapter Debtor / AFFIDAVIT OF CLAIMANT I, claimant) , am (indicate status of ( ) the individual creditor (or authorized personal representative of the individual creditor) in whose name funds were deposited with the court who has granted a power of attorney to , a "funds locator" or attorney to submit an application to withdraw unclaimed funds on my behalf; or ( ) the duly authorized representative for the claimant "business" ; or , ( ) the debtor claiming funds deposited in the name of a creditor in this case who has granted a power of attorney to a "funds locator" or attorney, to submit an application on my behalf; or ( ) the debtor claiming funds deposited in the name of the debtor in this case who has granted a power of attorney to , a "funds locator" or attorney, to submit an application on my behalf; or ( ) the duly authorized representative for claimant "business" as indicated in the attached corporate power of attorney who has granted a power of attorney to a "funds locator" or attorney, to submit an application to withdraw unclaimed funds on my behalf; and I am seeking payment of unclaimed funds in the amount of $ deposited in this court in the name of and representing claim number (if no claim was filed write "scheduled" in blank space). 2. Claimant History: Substantiate claimant's right to funds, including but not limited to documents relating to sale of company, i.e. purchase agreements and/or stipulation by prior and new owner as to right of ownership of funds. Attach certified copies of all necessary documentation, including those which establish the chain of LF-28 (rev. 12/01/09) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com ownership of the original corporate claimant. Also attach a copy of an official government photo id to prove your identity. 3. I (or the "business" I represent as claimant) have neither previously received remittance for these funds nor have contracted with any other party other than the person named as a "funds locator" or attorney in paragraph one above to recover these funds. I hereby certify that the foregoing statements are true and correct to the best of my knowledge and belief. signature of claimant or representative of "business" claimant Dated: print name title Last Four Digits of Social Security # or Tax ID# (EIN #) (Note: attach a copy of an official government photo id such as a driver's license or passport") address Phone number signature of joint debtor (if applicable) print name Last Four Digits of Social Security # or Tax ID# (EIN #) (Note: attach a copy of an official government photo id such as a driver's license or passport") Sworn to and Subscribed before me on . NOTARY PUBLIC, AT LARGE STATE OF LF-28 (rev. 12/01/09) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF FLORIDA www.flsb.uscourts.gov In re: Case No. Chapter Debtor / AFFIDAVIT OF CLAIMANT I, claimant) , am (indicate status of ( ) the individual creditor (or authorized personal representative of the individual creditor) in whose name funds were deposited with the court who has granted a power of attorney to , a "funds locator" or attorney to submit an application to withdraw unclaimed funds on my behalf; or ( ) the duly authorized representative for the claimant "business" ; or , ( ) the debtor claiming funds deposited in the name of a creditor in this case who has granted a power of attorney to a "funds locator" or attorney, to submit an application on my behalf; or ( ) the debtor claiming funds deposited in the name of the debtor in this case who has granted a power of attorney to , a "funds locator" or attorney, to submit an application on my behalf; or ( ) the duly authorized representative for claimant "business" as indicated in the attached corporate power of attorney who has granted a power of attorney to a "funds locator" or attorney, to submit an application to withdraw unclaimed funds on my behalf; and I am seeking payment of unclaimed funds in the amount of $ deposited in this court in the name of and representing claim number (if no claim was filed write "scheduled" in blank space). 2. Claimant History: (Substantiate claimant's right to funds, including but not limited to documents relating to sale of company, i.e. purchase agreements and/or stipulation by prior and new owner as to right of ownership of funds. Attach certified copies of all necessary LF-28 (rev. 12/01/09) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com documentation, including those which establish the chain of ownership of the original corporate claimant. Also attach a copy of an official government photo id to prove your identity.) 3. I (or the "business" I represent as claimant) have neither previously received remittance for these funds nor have contracted with any other party other than the person named as a "funds locator" or attorney in paragraph one above to recover these funds. I hereby certify that the foregoing statements are true and correct to the best of my knowledge and belief. signature of claimant Dated: print name title Last Four Digits of Social Security # or Tax ID# (EIN #) (Note: attach a copy of an official government photo id such as a driver's license or passport) address Phone number signature of joint debtor (if applicable) print name Last Four Digits of Social Security # or Tax ID# (EIN #) (Note: attach a copy of an official government photo id such as a driver's license or passport) Sworn to and Subscribed before me on . NOTARY PUBLIC, AT LARGE STATE OF LF-28 (rev. 12/01/09) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com
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