Application For Payment Of Unclaimed Funds {NM LF 347-1}

NM LF 347UNITED STATES BANKRUPTCY COURT DISTRICT OF NEW MEXICO In re: , Case No. Debtor. APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS The undersigned applies to the Court for an order directing payment of unclaimed funds. The following information is true and correct to the best of my knowledge and belief: 1.Claim Information. Owner of Claim as listed in the Court222s records: . Owner222s last 4 SSN or EIN:. Amount of Claim: $ . 2.Applicant Information (check all that apply). [ ] I am the owner. [ ] I am an officer, employee, etc. of the owner. I have attached documentation establishing my authority to file this petition on behalf of the owner. [ ] I am the attorney-in-fact for the owner. I have attached an original notarized power of attorney authorizing me to file this petition on the owner222s behalf. [ ] 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. [ ] I am an officer, employee, attorney-in-fact, etc. of the successor claimant, who is legally entitled to the claim listed above. I have attached documentation establishing my authority to file this petition on behalf of the successor claimant. [ ] Other information not covered above: . American LegalNet, Inc. www.FormsWorkFlow.com -2- 3.No Knowledge of Another Claimant. 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 thefunds. 4.Criminal Penalties for False statements. I understand that, pursuant to 18 U.S.C. 247152, I will be fined not more than $5,000.00, or imprisoned for not more than five years, orboth, if I have knowingly and fraudulently made any false statements in this document. 6.Photo Identification; W-9. A photocopy of my government-issued photo identification (e.g., driver222s license or passport) is attached. A completed IRS form W-9is also attached. 7.Notice to the United States Attorney. In accordance with 28 U.S.C. 2472042, claimant certifies that a copy of this Application (and related attachments) has beenmailed to the United States Attorney222s Office, P.O. Box 607, Albuquerque, NM 87103 onthe date shown below. I certify under penalty of perjury, that the foregoing statements are true and correct to the best of my knowledge and belief. Date . Signature: Name and title (type or print): Street address: City, state, zip: Telephone number: Email address: Submit the application and supporting documentation, a completed IRS form W-9, and a copy of photo identification to: American LegalNet, Inc. www.FormsWorkFlow.com