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UNITED STATES BANKRUPTCY COURT FOR THE SOUTHERN DISTRICT OF IOWA
P.O. Box 9264 Des Moines, Iowa 50306-9264 www.iasb.uscourts.gov

In the Matter of:

Case No.

IDENTIFICATION FORM FOR UNCLAIMED FUNDS CORPORATE/BUSINESS

I, _________________________________________, hereby state that I am the __________________________________, of ________________________________________ (Title) (Business Name) and I am authorized to request payment of the unclaimed funds referenced in the attached Motion. I am enclosing the attached document(s), including but not limited to corporate documents (if applicable) showing proof of ownership of funds through amendment (such as a name change), assignment, assumption, merger, and/or dissolution, and proper authority to act on behalf of the corporation (if applicable), that substantiate(s) my authorization.

(CORPORATE SEAL)

Signature: Name: Address: Telephone:

ATTACH A PHOTOCOPY OF A BUSINESS CARD
J:\Web\Forms\PDF Files\ID Corp Unclaimed Funds.pdf 5/27/09