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UNITED STATES BANKRUPTCY COURT DISTRICT OF OREGON In re ) ) ) ) Case No. __________________ PETITION FOR UNCLAIMED FUNDS AND ORDER THEREON

Debtor(s)

I, the undersigned petitioner, 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 petitioning to receive $____________, the total of all money deposited with the court by the trustee on the following date(s) _________________________________, on behalf of the debtor(s) or creditor named _______________ _____________________________________________________________, whose SSN/Tax ID# is _________________. 2. [Please check and complete only the ONE applicable subparagraph below]: A. I am the creditor/debtor named in point 1; and, if creditor/debtor not an individual, my title is (e.g., owner, partner, etc.) __________________________________________________________________________________________________. B. I am an employee of the creditor/debtor named in point 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 point 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 address, phone number, and a brief history of the creditor/debtor named in point 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): __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ 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.)]: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ 391 (12/1/08) Page 1 of 2

3. I have no knowledge that any other party may be entitled to, and am not aware of any dispute regarding, the funds at issue. 4. Enclosed is a photocopy of photo identification (e.g., driver's license or passport) of the petitioner named below. 5. I understand that, pursuant to 18 U.S.C. §152, I will be fined not more than $5,000.00, or imprisoned for 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 PORTLAND office of the Clerk, U.S. Bankruptcy Court, 1001 SW 5th Ave, #700, Portland OR 97204; AND (b) a copy to the U.S. Attorney, 1000 SW 3rd Ave. #600, Portland, OR 97204, per 28 U.S.C. §2042. 7. I CERTIFY that, if this document was not created using the court's PDF version of Local Form #391, this document IS IDENTICAL in format and text TO Local Form #391.

Date executed by petitioner ___________

____________________________________________________ Petitioner's Signature(s) ____________________________________________________ Petitioner's Name(s) (Type or Print) Telephone Number ____________________________________________________ Petitioner's Address ____________________________________________________

APPROVED AS TO FORM:

_________________________________ Financial Administrator

391 (12/1/08) Page 2 of 2