Application For Unclaimed Funds {H1340}

UNITED STATES BANKRUPTCY COURT DISTRICT OF HAWAII 1132 Bishop Street, Suite 250 Honolulu, Hawaii 96813 hib_3011-1 (1/11) Debtor: Joint Debtor: (if any) Case No.: Chapter: APPLICATION FOR UNCLAIMED FUNDS 1. Claim Information Application is hereby made for disbursement of the following previously unclaimed funds on deposit with the court for the benefit of the claimant named below. Amount: Claimant's Name: Claimant's Address: (at time claim was made) *Provide documentation that Claimant resided or did business at this address. Claimant's Current Address: (if different from above) Last 4 digits of Claimant's SSN or Complete EIN 2. Applicant Information The applicant is: The individual claimant named above. Photo identification is attached. An individual authorized to act on behalf of the corporation, partnership, limited liability company, or other artificial entity named above. Documentation showing authority to make this application is attached. The legal representative of the claimant named above. An original, notarized power of attorney is attached, or, if the claimant is deceased, a certified copy of a letter of administration or probated will is attached. The successor in interest to the claimant named above. Documentation showing entitlement to the funds through amendment, merger, or dissolution is attached. The payee's taxpayer information (Form W-9) is attached. No payment will be made unless a completed and signed Form W-9 is submitted with the application. American LegalNet, Inc. www.FormsWorkFlow.com 3. Service on United States Attorney The undersigned understands that a copy of this application and supporting documentation must be sent to the United States Attorney at the following address: Office of the United States Attorney District of Hawaii 300 Ala Moana Boulevard, Room 6100 Honolulu, HI 96850. 4. Declaration The undersigned declares, under penalty of perjury, that the information contained in this application and any accompanying documentation is true and correct. I also understand that, pursuant to 18 U.S.C. § 152, I may be fined not more than $250,000, or imprisoned not more than 5 years if I have knowingly and fraudulently made any false statements in this document or provided false documentation as part of this application. ___________________________ Date Phone: _____________________ Email: _________________________ ___________________________ Signature of Applicant ___________________________ Printed Name of Applicant Address: __________________________________________________ __________________________________________________ __________________________________________________ 5. Notarization STATE OF ____________________________, COUNTY OF __________________________________________ This 2-page 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 on: _________________________ This application may be filed with the court at the following address: UNITED STATES BANKRUPTCY COURT DISTRICT OF HAWAII 1132 Bishop Street, Suite 250 Honolulu, HI 96813. American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES BANKRUPTCY COURT DISTRICT OF HAWAII 1132 Bishop Street, Suite 250 Honolulu, Hawaii 96813 hib_3011-1 (1/11) Debtor: Joint Debtor: (if any) Case No.: Chapter: APPROVAL OF APPLICATION FOR UNCLAIMED FUNDS Name of Claimant: Applicant's Name and Address: (Check will be sent to this address) VERIFICATION OF FUNDS ON DEPOSIT The court's financial records indicate that funds in the following amount are being held for the claimant named above: _________________________ Date ________________________________ Deputy Clerk STATEMENT BY UNITED STATES ATTORNEY The undersigned is authorized to make this statement on behalf of the United States Attorney for the District of Hawaii. The United States Attorney has no objection to the payment of unclaimed funds to the applicant named above. _________________________ Date _______________________________________________________ for the United States Attorney Name and Title $ ___________________ ORDER APPROVING APPLICATION FOR UNCLAIMED FUNDS For good cause, IT IS HEREBY ORDERED that the application for unclaimed funds is APPROVED. The clerk may disburse the above amount of funds to the applicant named above. _________________________ Date ________________________________ United States Bankruptcy Judge American LegalNet, Inc. www.FormsWorkFlow.com Form (Rev. October 2007) Department of the Treasury Internal Revenue Service W-9 Request for Taxpayer Identification Number and Certification Give form to the requester. Do not send to the IRS. Name (as shown on your income tax return) Print or type See Specific Instructions on page 2. Business name, if different from above Check appropriate box: Individual/Sole proprietor Corporation Partnership Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership) Other (see instructions) Address (number, street, and apt. or suite no.) Exempt payee Requester's name and address (optional) City, state, and ZIP code List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Social security number Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. or Employer identification number Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am