Free Corel Office Document - Arkansas

UNITED STATES BANKRUPTCY COURT EASTERN AND WESTERN DISTRICTS OF ARKANSAS Procedures for Withdrawal of Unclaimed Funds Applications for payment of unclaimed funds will only be processed when filed by either the owner of the funds or the owner's duly authorized agent or representative. Upon receipt of the application (see next page for fillable PDF application), the financial department will review the application and supporting documentation for accuracy and validity, verify that the requested funds remain on deposit with the Court, and forward the application and supporting documentation to the Bankruptcy Judge for final disposition. All checks issued as a result of an application submitted by an attorney or "funds locator" who has been retained by the claimant or other party entitled to the funds shall be made payable to the applicant and the claimant (or successor in interest to the original claimant). If the application is signed by an individual on behalf of a non individual, the check will be issued in the non individual (i.e. company) name. Questions concerning these procedures should be directed to the Financial Officer, U. S. Bankruptcy Court, 300 W. 2nd Street, Little Rock, Arkansas 72201, (501) 918-5512 or (501) 918-5510.

UNITED STATES BANKRUPTCY COURT EASTERN AND WESTERN DISTRICTS OF ARKANSAS In re: ____________________________ Case No. _____________________

APPLICATION FOR UNCLAIMED FUNDS I, the undersigned, under penalty of perjury under the laws of the United States of America, declare (or certify, verify, or state) that the following statements and information are true and correct: 1. I am applying to receive $_________________, the total of all money deposited with the court by the trustee on behalf of the debtor or creditor whose name is ___________________________________________________and whose SSN/Tax ID#___________________. 2. [Please check and complete only the ONE applicable subparagraph below]: A. I am the creditor/debtor named in paragraph 1; and if not an individual, my title is (e.g., owner, partner, etc.) _________________________________________________________________________________________________. B. I am an employee of the creditor/debtor named in paragraph 1 and my title is _______________________________. The creditor/debtor is still legally entitled to the money and I am authorized by such creditor/debtor to file this petition. C. I am the lawful attorney-in-fact for the creditor/debtor named in paragraph 1 and I am duly authorized by the attached original notarized power of attorney to file this petition. I am aware of all pertinent state law requirements regarding powers of attorney. The following is the address, phone number, and a brief history of the creditor/debtor named in paragraph 1 (from filing of the claim to present) which includes, if applicable, identification of any sale of the company and the new and prior owner(s). Attach additional sheet(s) if necessary. __________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ D. Subparagraphs A, B & C above do not apply, but I am entitled to payment of such money because [state basis for your claim and provide certified copies of supportive documents (e.g., proof of the transfer of assets of the business originally entitled to the funds, sale of the company, probate documents to substantiate the right to act on behalf of the descendant's estate,etc.)]:________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ 3. I have no knowledge that any other party may be entitled to these funds and am not aware of any dispute regarding these funds. 4. Enclosed is a photocopy of photo identification (e.g., driver's license or passport) of the applicant named below. 5. I understand that, pursuant to 18 U.S.C. §152, I will be fined not more than $5,000, or imprisoned not more than five years, or both, if I have knowingly and fraudulently made any false statements in this document. 6. On ______________ I mailed BOTH: (a) the ORIGINAL of this document (fully completed) to the office of the Clerk, U.S. Bankruptcy Court, 300 W. Second St., Little Rock AR 72201; AND (b) a COPY to the U.S. Attorney at P. O. Box 1524, Fort Smith, AR 72902 (Western District) or P. O. Box 1229, Little Rock, AR 72203 (Eastern District), per 28 U.S.C. §2042. ___________________________________________ Applicant's Name (Type or Print) ____________________________________________ Applicant's signature (Bar # if attorney)

___________________________________________ Applicant's Telephone Number

___________________________________________ Applicant's Street Address

___________________________________________ Date

___________________________________________ Applicant's City, State, and Zip