Fillable APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS (US Courts)

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APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS (US Courts)

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  • 6 check-boxes
  • 39 other fields

Country of origin: US
File type: PDF

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Form 1340 (12/19)
APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS
1. Claim Information
For the benefit of
the Claimant(s)
1
named below, application is made for the payment of unclaimed funds on deposit with
the court. I have no knowledge that any other party may be entitled to these funds, and I am not aware of any dispute
regarding these funds.
Note: If there are joint Claimants, complete the fields below for both Claimants.
Amount:
Claimant’s Name:
Claimant’s Current Mailing
Address, Telephone Number,
and Email Address:
2. Applicant Information
Applicant
2
represents that Claimant is entitled to receive the unclaimed funds because (check the statements that
apply):
□
Applicant is the Claimant and is the Owner of Record
3
entitled to the unclaimed funds appearing on the records of
the court.
□
Applicant is the Claimant and is entitled to the unclaimed funds by assignment, purchase, merger, acquisition,
succession or by other means.
□
Applicant is Claimant’s representative (e.g., attorney or unclaimed funds locator).
□
Applicant is a representative of the deceased Claimant’s estate.
3. Supporting Documentation
□
Applicant has read the court’s instructions for filing an Application for Unclaimed Funds and is providing the required
supporting documentation with this application.
1
The Claimant is the party entitled to the unclaimed funds.
2
The Applicant is the party filing the application. The Applicant and Claimant may be the same.
3
The Owner of Record is the original payee.
Debtor 1 ______________________________________________
First Name Middle Name Last Name
Debtor 2 ______________________________________________
(Spouse, if filing) First Name Middle Name Last Name
United States Bankruptcy Court for the: _________ District of ______________
(State)
Case number:
Fill in this Information to identify the case:
Revised: 20191203
Form: U-1b
Form 1340 Application for Payment of Unclaimed Funds Page 2
4. Notice to United States Attorney
□
Applicant has sent a copy of this application and supporting documentation to the United States Attorney,
pursuant to 28 U.S.C. § 2042, at the following address:
Office of the United States Attorney
District of
5. Applicant Declaration
Pursuant to 28 U.S.C. § 1746, I declare under penalty of
perjury under the laws of the United States of America
that the foregoing is true and correct.
Date: ____________________________
_______________
________________________________
Signature of Applicant
_______________
________________________________
Printed Name of Applicant
Address:
Telephone: _______
_________________
Email: _______
________________
5. Co-Applicant Declaration (if applicable)
Pursuant to 28 U.S.C. § 1746, I declare under penalty of
perjury under the laws of the United States of America
that the foregoing is true and correct.
Date: ____________________________
_______________
______________________________
Signature of Co-Applicant (if applicable)
_______________
______________________________
Printed Name of Co-Applicant (if applicable)
Address:
Telephone: _______
_________________
Email: _______
________________
6. Notarization
STATE OF
COUNTY OF
This Application for Unclaimed Funds, dated
was subscribed and sworn to before
me this day of , 20 by
who signe
d above and is personally known to me (or
proved to me on the basis of satisfactory evidence) to be
the person whose name is subscribed to the within
instrument. WITNESS my hand and official seal.
(SEAL) Notary Public
My commission expires:
6. Notarization
STATE OF
COUNTY OF
This Application for Unclaimed Funds, dated
was subscribed and sworn to before
me this day of , 20 by
who signed a
bove and is personally known to me (or
proved to me on the basis of satisfactory evidence) to be
the person whose name is subscribed to the within
instrument. WITNESS my hand and official seal.
(SEAL) Notary Public
My commission expires:
Chief Civil Division
U.S. Attorney's Office
219 South Dearborn Street
Chicago, Illinois 60604
Northern
Illinois
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APPLICATION FOR PAYMENT OF UNCLAIMED FUNDS (US Courts)

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Completed 6 September 2021

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