Procedures Form For Withdrawal Of Unclaimed Funds Page 2
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1
2UNITED STATES BANKRUPTCY COURT
EASTERN AND WESTERN DISTRICTS OF ARKANSAS
In re: ____________________________
Case No. _____________________
APPLICATION FOR UNCLAIMED FUNDS
I, the undersigned, under penalty of perjury under the laws of the United States of America, declare (or certify, verify,
or state) that the following statements and information are true and correct:
1. I am applying to receive $_________________, the total of all money deposited with the court by the trustee on behalf
of the
debtor or
creditor whose name is ___________________________________________________and whose
SSN/Tax ID#___________________.
2. [Please check and complete only the ONE applicable subparagraph below]:
A. I am the creditor/debtor named in paragraph 1; and if not an individual, my title is (e.g., owner, partner, etc.)
_________________________________________________________________________________________________.
B. I am an employee of the creditor/debtor named in paragraph 1 and my title is _______________________________.
The creditor/debtor is still legally entitled to the money and I am authorized by such creditor/debtor to file this petition.
C. I am the lawful attorney-in-fact for the creditor/debtor named in paragraph 1 and I am duly authorized by the attached
original notarized power of attorney to file this petition. I am aware of all pertinent state law requirements regarding powers
of attorney. The following is the address, phone number, and a brief history of the creditor/debtor named in paragraph 1 (from
filing of the claim to present) which includes, if applicable, identification of any sale of the company and the new and prior
owner(s). Attach additional sheet(s) if necessary. __________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
D. Subparagraphs A, B & C above do not apply, but I am entitled to payment of such money because [state basis for your
claim and provide certified copies of supportive documents (e.g., proof of the transfer of assets of the business originally
entitled to the funds, sale of the company, probate documents to substantiate the right to act on behalf of the descendant's
estate,etc.)]:________________________________________________________________________________________
_________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
3. I have no knowledge that any other party may be entitled to these funds and am not aware of any dispute regarding these
funds.
.
4
Enclosed is a photocopy of photo identification (e.g., driver's license or passport) of the applicant named below.
.
5
I understand that, pursuant to 18 U.S.C. §152, I will be fined not more than $5,000, or imprisoned not more than five years,
or both, if I have knowingly and fraudulently made any false statements in this document.
.
6
On ______________ I mailed BOTH: (a) the ORIGINAL of this document (fully completed) to the office of the Clerk,
U.S. Bankruptcy Court, 300 W. Second St., Little Rock AR 72201; AND (b) a COPY to the U.S. Attorney at P. O. Box 1524,
Fort Smith, AR 72902 (Western District) or P. O. Box 1229, Little Rock, AR 72203 (Eastern District), per 28 U.S.C. §2042.
___________________________________________
____________________________________________
Applicant’s Name (Type or Print)
Applicant’s signature
(Bar # if attorney)
___________________________________________
___________________________________________
Applicant’s Telephone Number
Applicant’s Street Address
___________________________________________
___________________________________________
Date
Applicant’s City, State, and Zip
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