Free Report of Deposit of Small Dividends - Virginia

UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF VIRGINIA
[Division]

Division Case No.
[Case No.] [Chapter]

In re [Name of Debtor]
[Name of Joint Debtor]

Debtor(s)

Chapter

REPORT OF DEPOSIT OF SMALL DIVIDEND ________________________________________________________________________
Pursuant to Federal Rule of Bankruptcy Procedure 3010 and 11 U.S.C. 347, the trustee submits a check payable to "Clerk, United States Bankruptcy Court" representing small dividends 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 small dividends represent the dividend(s) due and payable to: Creditor's Name and Address Amount of Dividend

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

[Current Date] Date: __________________

[Trustee Signature] ____________________________________ (Signature of Trustee) [Name of Trustee] ____________________________________ (Typed Name of Trustee) [State Bar No.] ____________________________________ (State Bar Number) [Street or P.O. Address, City, State & Zip] ____________________________________ (Address) [Telephone Number] ____________________________________ (Telephone Number)

[rsmdivid ver. R. 04/03]