Application For Payment Of Unclaimed Funds {F67}

UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF NEW YORK In re [Set forth here all names including married, maiden, and trade names used by debtor within last 8 years.] Debtor Employer's Tax Identification No(s). [if any] Last four digits of Social Security No(s): ) ) ) ) ) ) ) ) ) ) Case No. Chapter APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS of (Name of Claimant) (Address) , being duly sworn, deposes (SSN or Tax ID No.) (Telephone No.) and says: That he/she is a creditor of the above named debtor. That was duly adjudged a debtor in the United States Bankruptcy Court for the Northern District of New York. That said creditor duly filed his/her claim, which was thereafter duly allowed. remain unpaid. That dividends amounting to the sum of That the said claim has not been sold or assigned, and that it is still the property of the deponent. That the deponent is not aware of any dispute regarding the claim at Issue. It is therefore requested that the Clerk of the Court pay to (Name of Claimant) (Signature of Claimant) SUBSCRIBED AND SWORN to before me this day of Affix Seal F:67(10/02/2006 ) Notary Public American LegalNet, Inc. www.FormsWorkFlow.com