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UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF MICHIGAN

In re: Case No. __________________ Chapter

APPLICATION FOR PAYMENT FROM UNCLAIMED FUNDS

The undersigned, __________________________________, applies to the Bankruptcy Court for the Eastern District of Michigan for entry of an order directing the Clerk of the Court to remit to the applicant the sum of $___________________ , said funds having been deposited into the Treasury of the United States pursuant to an order of the Court as unclaimed funds for creditor . The applicant further states that: 1. (Indicate one of the following) _____ Applicant is the creditor named in the above case and states that no other application for this claim has been submitted by or at the request of the creditor Applicant is the duly authorized representative for the business or corporation named as the creditor. Applicant has reviewed all records of the creditor and states that no other application for this claim has been submitted by or at the request of this creditor. An Affidavit of Creditor is attached and made part of this application. Applicant is either a family member of the deceased creditor or a successor in interest to the individual or business named as the creditor. An original "power of attorney" conforming to the official Bankruptcy Form and/or other supporting documents which indicated the applicants' entitlement to this claim is attached and made part of this application.

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2.

Applicant has made sufficient inquiry and has no knowledge that this claim has been previously paid, that any other application for this claim is currently

pending before this court, or that any party other than the applicant is entitled to submit an application for this claim. Page 2 of 2 Application for Payment from Unclaimed Funds

Respectfully submitted this _____ day of ____________, 20___.

___________________________ Name of creditor

_____________________________ Signature of Applicant

__________________________________ Name and Title of Applicant __________________________________ Company Name __________________________________ Street Address __________________________________ City and State __________________________________ Telephone number __________________________________ Tax Identification XXX-XXSocial Security Number

_ ______________ Claim Number