Limited Power Of Attorney Form

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UNITED STATES BANKRUPTCY COURT
FOR THE SOUTHERN DISTRICT OF IOWA
110 E. Court Avenue, Ste 300
Des Moines, Iowa 50309
In the Matter of:
Case No.
LIMITED POWER OF ATTORNEY
To: (name address of agent/attorney-in-fact)
The undersigned claimant hereby authorized you to act as attorney-in-fact for the
undersigned only to collect uncollected, undistributed, or unclaimed funds held by the court and
owing to _________________________________________(name of claimant) in the amount of
$______________.
Dated:
Signature:
Name:
Address:
Telephone:
Social Security Number: XXX-XX-
Acknowledged before me on the ________ day of __________________, 20_____, by
10
_________________________________, who says that he/she is the person name above and is
authorized to execute this power of attorney.
Signature_________________________________
Notary Public
J:\Web\Forms\PDF Files\POA Unclaimed Funds.pdf 7/13/10

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