Application For Payment Of Unclaimed Funds {ALNB LBF 1340}

Fill in this Information to identify the case: Debtor 1 First Name Middle Name Last Name Debtor 2 (Spouse, if filing) First Name Middle Name Last Name United States Bankruptcy Court for the Northern District of Alabama Case number: ALNB LBF 1340 (8/19) APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS 1.Claim Information For the benefit of the Claimant(s)1 named below, application is made for the payment of unclaimed funds on deposit with the court. I have no knowledge that any other party may be entitled to these funds, and I am not aware of any dispute regarding these funds. Note: If there are joint Claimants, complete the fields below for both Claimants. Amount: Claimant222s Name: Claimant222s Current Mailing Address, Telephone Number, and Email Address: 2.Applicant Information Applicant2 represents that Claimant is entitled to receive the unclaimed funds because (check the statements that apply): Applicant is the Claimant and is the Owner of Record3 entitled to the unclaimed funds appearing on the records of the court. Applicant is the Claimant and is entitled to the unclaimed funds by assignment, purchase, merger, acquisition, succession or by other means. Applicant is Claimant222s representative (e.g., attorney or unclaimed funds locator). Applicant is a representative of the deceased Claimant222s estate. 3.Supporting Documentation Applicant has read the court222s instru ctions for filing an Application for Unclaimed Funds and is providing the required supporting documentation with this application. 1 The Claimant is the party entitled to the unclaimed funds. 2 The Applicant is the party filing the application. The Applicant and Claimant may be the same. 3 The Owner of Record is the original payee. American LegalNet, Inc. www.FormsWorkFlow.com 4.Notice to United States Attorney Applicant has sent a copy of this application and supporting documentation to the United States Attorney, pursuant to 28 U.S.C. 247 2042, at the following address: Office of the United States Attorney Northern District of Alabama 1801 Fourth Avenue North Birmingham, AL 35203 5 . Applicant Declaration Pursuant to 28 U.S.C. 247 1746, I declare under penalty ofperjury under the laws of the United States of Americathat the foregoing is true and correct. Date: Signature of Applicant Printed Name of Applicant Address: Telephone: Email: 5.Co - Applicant Declaration (if applicable) Pursuant to 28 U.S.C. 247 1746, I declare under penalty ofperjury under the laws of the United States of Americathat the foregoing is true and correct. Date: Signature of Co-Applicant (if applicable) Printed Name of Co-Applicant (if applicable) Address: Telephone: Email: 6.Notarization STATE OF COUNTY OF This Application for Unclaimed Funds, dated was subscribed and sworn to before me this day of , 20 by who signed above and is personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument. WITNESS my hand and official seal. (SEAL) Notary Public My commission expires: 6.Notarization STATE OF COUNTY OF This Application for Unclaimed Funds, dated was subscribed and sworn to before me this day of , 20 by who signed above and is personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument. WITNESS my hand and official seal. (SEAL) Notary Public My commission expires: ALNB LBF 1340 Application for Payment of Unclaimed Funds Pa . American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF SERVICE In accordance with 28 U.S.C. 247 2042, the undersigned hereby certifies that on the date designated below, a true and correct copy of the foregoing application with all required documentation was mailed to: United States Attorney for Northern District of Alabama 1801 Fourth Ave North Birmingham, AL 35 2 03. Names and addresses of all other parties served: Date: (Signature) (Name Printed) (Street or P O Box Address) (City) (State) (Zip Code) American LegalNet, Inc. www.FormsWorkFlow.com