Application For Payment From Unclaimed Funds, Form W-9 - Request For Taxpayer Identification Number And Certification - 2011

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UNITED STATES BANKRUPTCY COURT
WESTERN DISTRICT OF LOUISIANA
IN RE:
CASE NO:
(debtor and/or co-debtor)
APPLICATION FOR PAYMENT FROM UNCLAIMED FUNDS
Comes now the Claimant identified below, to make application for an Order authorizing
payment of unclaimed funds now on deposit in the Registry of the Court in the Western District of
Louisiana.
NAME OF CLAIMANT:
CURRENT ADDRESS:
The dividend(s) listed below which were awarded to the Claimant in the above captioned
bankruptcy case was/were not delivered to Claimant due to:
(state reason).
The Trustee delivered the unclaimed funds to the Clerk of Court pursuant to 11 USC 347.
Date of Transmittal
Dividend Amount
$0.00
TOTAL
Claimant certifies under penalty of perjury that all statements made by Claimant on this
application are, to the best of Claimant’s knowledge, true and correct. Accordingly, Claimant requests
the Court to enter an Order authorizing payment to Claimant at the above mentioned address.
Claimant further certifies that a copy of this application has been mailed to the U.S. Attorney,
300 Fannin St., Suite 3201, Shreveport, LA 71101.
Signature:
Company Name:__________________
Person Signing:___________________
Title:____________________________
(attach photocopy of drivers license, supporting documentation, and IRS Form W-9 to application)
F:\Unclaimed Funds\Instructions, Application, Forms, etc\Application for Payment - Corporation - v4-1-13.wpd
Rev. 4-1-13

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