Application for Payment of Unclaimed Funds

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Application for Payment of Unclaimed Funds Powered By Docstoc
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 3                               UNITED STATES DISTRICT COURT
 4                           NORTHERN DISTRICT OF CALIFORNIA
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 6                                                      )
     ENTER PLAINTIFF NAME(S).,                          )       Case Number:   CASE #
 7                                                      )
                    Plaintiff(s),                       )       APPLICATION FOR PAYMENT OF
 8                                                      )       UNCLAIMED FUNDS;
            vs.                                         )
 9                                                      )       CERTIFICATE OF SERVICE;
     ENTER DEFENDANT NAME(S).                           )       PROPOSED ORDER
10                                                      )
                    Defendant(s).                       )
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                                                        )
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13   1.     I am making application to receive $ ENTER $ AMOUNT, which was deposited as unclaimed
     funds on behalf of:
14   2.     Applicant is entitled to receive the requested funds, has made sufficient inquiry and has
15   no knowledge that any other party may be entitled to, and is not aware of any dispute
     regarding the funds at issued based upon the following (check all statement(s) that apply):
16           ☐    Applicant is the owner of record named in ¶ 1, and the owner of the funds appearing on
                  the records of this Court, as evidenced by the attached documents.
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             ☐    Applicant is the successor business for the owner of record named in ¶ 1, with authority to
18                receive such funds, or who is authorized by the attached notarized, original Power of
                  Attorney to file this application on behalf of the successor business and documents
19                establishing chain of ownership and/or assignment.
             ☐    Applicant is the successor claimant for the owner of record named in ¶ 1 as evidenced by
20                the attached documents establishing transfer of ownership and/or assignment.
21           ☐    Applicant is an administrator, executor or representative of the deceased owner of record
                  named in ¶ 1, as evidenced by the attached certified copies of the death certificate and
22                other appropriate probate documents substantiating applicant’s right to act on behalf of
                  the decedent’s estate.
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             ☐    Applicant is the representative (i.e., funds locator) of the owner of record named in ¶ 1, as
24                evidenced by the attached notarized, original Power of Attorney on whose behalf the
                  representative is acting.
25           ☐    None of the above applies. As evidenced by the attached documents, applicant is entitled
                  to these unclaimed funds because:
26                ENTER EXPLANATION HERE.

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 1           I declare under penalty of perjury under the laws of the United States of America that the
     foregoing statements and information are true and correct.
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     Dated: Click      here    to   enter     a   date.
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                                           SIGNATURE:
 4
 5                             NAME OF APPLICANT:

 6                          ADDRESS OF APPLICANT:

 7
 8                 PHONE NUMBER OF APPLICANT:

 9                                   NOTARIAL ACKNOWLEDGEMENT

10   State of California

11   County of _____________________________

12           On _________________ before me, ___________________________ personally appeared

13   __________________________________, who proved to me on the basis of satisfactory evidence

14   to be the person(s) whose name(s) is/are subscribed to the within instrument and

15   acknowledged to me that he/she/they executed the same in his/her/their authorized

16   capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the
     entity upon behalf of which the person(s) acted, executed the instrument.
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             I certify under PENALTY OF PERJURY under the laws of the State of California that the
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     foregoing paragraph is true and correct.
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     WITNESS my hand and official seal.
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     Signature ______________________________ & Seal
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                                                          2
 1
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 3                                 UNITED STATES DISTRICT COURT
 4                            NORTHERN DISTRICT OF CALIFORNIA
 5
                                                     )
 6   ENTER PLAINTIFF NAME(S).,                       ) Case Number: CASE #
                                                     )
 7                   Plaintiff(s),                   ) CERTIFICATE OF SERVICE
                                                     )
 8          vs.                                      )
                                                     )
 9   ENTER DEFENDANT NAME(S).                        )
                                                     )
10                   Defendant(s).                   )
                                                     )
11                                                   )
12   I certify that on Click here to enter a date.(date), a true and correct copy of this

13   application for payment of unclaimed funds was served by first class United States Mail on:

14   Office of the United States Attorney
     Northern District of California
15   450 Golden Gate Ave.
     San Francisco, CA 94102
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     and the following party(ies) who may have an interest in the funds pursuant to 28 U.S.C. §2042:
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     Dated:Click     here     to     enter   a   date.
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                                       SIGNATURE:
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                                     PRINT NAME:
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 1
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 3                                UNITED STATES DISTRICT COURT
 4                             NORTHERN DISTRICT OF CALIFORNIA
 5
 6                                                 )
     ENTER PLAINTIFF NAME(S).,                     ) Case Number: CASE #
 7                                                 )
                      Plaintiff(s),                ) [PROPOSED] ORDER FOR
 8                                                 ) PAYMENT OF UNCLAIMED FUNDS
              vs.                                  )
 9                                                 )
     ENTER DEFENDANT NAME(S).                      )
10                                                 )
                      Defendant(s).                )
11                                                 )
                                                   )
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13   Upon the application of APPLICANT NAME (“Applicant”), seeking payment of $ENTER $ AMOUNT
     representing funds previously unclaimed by ENTER NAME OF DEPOSITOR OF FUNDS, a party in the
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     above-entitled case, and it appearing from the application and supporting documentation that
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     Applicant is entitled to the unclaimed funds, the Court now orders that the Clerk pay $ENTER $
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     AMOUNT   to Applicant.
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     IT IS SO ORDERED.
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20   Dated:

21                                          UNITED STATES DISTRICT/MAGISTRATE JUDGE
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