Free LBR Form F.2 - Rhode Island

R.I. Bankr. Form F.2 See R.I. LBR 3011-1(b)

UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF RHODE ISLAND CORPORATE/BUSINESS IDENTIFICATION FORM FOR UNCLAIMED DIVIDENDS Case Name Case No. Amount of dividend/refund

A dividend/refund check was previously issued in your name in accordance with an Order of this Court, however said check was not cashed and has been deposited with the United States Treasury Account. In order to insure payment to the proper party, please fill out the identification portion on this form and mail to: U.S. Bankruptcy Court, 380 Westminster Mall, Providence, RI 02903, Attn: Financial Dept. Upon receipt of the completed document, your request for payment of unclaimed funds held by the Court will be processed. ================================================================== I, Of (Title) (Business Name) , hereby state that I am the

and am authorized to request payment of the above dividend.

(Signature)

(Corporate Seal)

Subscribe and sworn to before me in (City/Town) This (State) Day of , 20 .

(Notary Public)