Application For Payment Of Unclaimed Funds printable pdf download

Application For Payment Of Unclaimed Funds

BTXN 127 (rev. 1/14)

UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF TEXAS

In Re:

Case No.:

Debtor(s)

APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS

Comes now the undersigned, to make application for an order directing payment of unclaimed funds

now on deposit in the Treasury of the United States. Claimant is a

creditor

debtor (check one)

in the above captioned bankruptcy case and on whose behalf these funds were deposited.

Name of Claimant(s)

Name and Title of Authorizing

Officer or Representative

(If Claimant is an individual, skip

to Question No. 3)

Current Mailing Address

Telephone Number

SS# (last 4 digits only) or EIN #

Amount Being Claimed

,do hereby state under penalty of perjury that I am legally

entitled to claim these funds for whom the unclaimed funds were deposited into the treasury in the above

referenced bankruptcy case. I certify to the best of my knowledge that all information submitted in support

of this claim is true and correct.

Date

Claimant Signature

Co-Claimant Signature

Subscribed and Sworn to Before Me this

day of

Notary Public

In and for the State of

My commission expires

Application For Payment Of Unclaimed Funds