Petition For Unclaimed Funds And Order Thereon {391}

391 (12/1/2018) Page 1 of 3 UNITED STATES BANKRUPTCY COURT DISTRICT OF OREGON In re ) Case No. ) ) Petition for Unclaimed ) Funds and Order Thereon Debtor(s) ) (Photo ID of Petitioner Required) I hereby petition the Court to enter an order directing payment of unclaimed funds in accordance with this petition and the attached documents. 1. CLAIM INFORMATION Owner of Claim as listed in the Court222s records: Owner222s SSN or EIN: Amount of Claim: $ 2. PETITIONER INFORMATION. Please check the option that best describes your relationship to the owner. IF OWNER IS AN INDIVIDUAL: I am the owner. I am the lawful attorney-in-fact for the owner or successor claimant. I have attached an original notarized power of attorney authorizing me to file this petition on behalf of the owner or successor claimant. (If petitioning on behalf of a successor claimant, petitioner must also attach documentation showing each transfer of ownership.) American LegalNet, Inc. www.FormsWorkFlow.com 391 (12/1/2018) Page 2 of 3 I am a personal representative, administrator, executor, or beneficiary of the owner222s estate. Attached are certified copies of documents establishing my right to act on behalf of the estate. I am a successor claimant. I have attached documentation showing each transfer of ownership. (If successor claimant is a business, petitioner must also comply with the requirements listed in the next section.) IF OWNER IS A CORPORATION, LLC, PARTNERSHIP, ETC.: I am an officer, employee, etc., of the original owner, who is still legally entitled to the claim listed above. I have attached documentation establishing my authority to file this petition on behalf of the owner. I am filing this claim on behalf of a successor claimant (e.g., successor business, assignee, etc., who now has a direct claim to the funds but is not the owner of record). I have attached documentation establishing the chain of ownership, a statement of my authority to file this petition, and a notarized power of attorney signed by an officer of the successor claimant. I am the lawful attorney-in-fact for the owner. I have attached an original notarized power of attorney authorizing me to file this petition on behalf of the owner. 3. I declare that I have no knowledge that any other party may be entitled to these funds, and I am not aware of any dispute regarding the funds. 4. I understand that, pursuant to 18 U.S.C. 247 152, I will be fined, or imprisoned for not more than five years, or both, if I have knowingly and fraudulently made any false statements in this document. 5. I certify that on the date shown below, I mailed a copy of this document with all attachments to the U.S. Attorney, Attn: Civil Process Clerk, 1000 SW 3rd Ave. #600, Portland, OR 97204, per 28 U.S.C. 247 2042. The person(s) signing below must attach a photocopy of government-issued photo identification (e.g., driver222s license or passport). American LegalNet, Inc. www.FormsWorkFlow.com 391 (12/1/2018) Page 3 of 3 Under penalty of perjury, I hereby certify that the foregoing statements are true and correct to the best of my knowledge and belief. Dated Signature of Petitioner Petitioner222s Name and Title (Type or Print) Petitioner222s Telephone Number Email Address Petitioner222s Street Address City/State/Zip Signature of Joint Petitioner (required if two owners of record) Joint Petitioner222s Name (Type or Print) State of ) ) ss County of ) On before me, personally appeared (insert name and title of signer(s)) personally known to me, or proved to me on the basis of satisfactory evidence, to be the person(s) who executed the within foregoing instrument, and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and by his/her/their signature(s) on the instrument the person(s), or the entity on behalf of which the person(s) acted, executed the instrument. Notary Public My commission expires on (SEAL) Submit this petition with any supporting documentation and a copy of photo identification to: Financial Administrator, U.S. Bankruptcy Court, 1050 SW 6th Ave. #700, Portland OR 97204 American LegalNet, Inc. www.FormsWorkFlow.com