UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF VIRGINIA Division
In re Debtor(s) Case No. Chapter

REPORT OF DEPOSIT OF UNCLAIMED FUNDS ________________________________________________________________________ Pursuant to Federal Rule of Bankruptcy Procedure 3011 and 11 U.S.C. 347, the trustee herein submits a check payable to "Clerk, United States Bankruptcy Court" representing unclaimed funds to be deposited by the Clerk of Court into the Treasury of the United States. Said funds are subject to withdrawal as provided by 28 U.S.C. 2042 and shall not escheat under any state law. The unclaimed funds represent the dividend(s) due and payable to: Creditor's Name and Address Amount of Dividend

[If applicable: Continued on attached page(s).]

Date: __________________________

________________________ (Signature of Trustee)
[Name of Trustee] ________________________ (Typed Name of Trustee)

[runclmfd ver. R. 04/03]