UNITED STATES BANKRUPTCY COURT FOR THE SOUTHERN DISTRICT OF WEST VIRGINIA
Case Name:
________________________________ ________________________________
Case Number ___________________ Chapter ______
TRUSTEE FUNDS SUBMISSION FORM
_____ Attached is a check in the amount of $_________________ for deferred filing fees or other court costs as listed below: Adversary Case No. _________________ Adversary Case No. _________________ Other: ____________________________ $___________ $___________ $___________
_____ Attached is a check in the amount of $___________ for claims under $5.00, to be treated as unclaimed funds pursuant to Bankruptcy Rule 3010(a). Such check consists of funds due to the claimant(s) listed below. _____ Attached is a check which reflects unclaimed funds in the amount of $______________, due to returned checks and for checks not presented for payment within 90 days, etc. Such check consists of funds returned from the claimant(s) listed below. CLAIM NUMBER _______ CLAIMANT (Name & address) _______________________________ _______________________________ _______________________________ ________________________________ ________________________________ ________________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ SSN (last 4 digits only) or FEIN (all digits) _____________ AMOUNT OF UNCLAIMED FUNDS $___________
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$___________
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$___________
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$___________
Dated: _______________________________ Trustee