UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

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) Case Number:
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Plaintiff(s), ) APPLICATION FOR PAYMENT OF
) UNCLAIMED FUNDS;
vs. )
) CERTIFICATE OF SERVICE;
) PROPOSED ORDER
)
Defendant(s). )
)
)

1. I am making application to receive $ , which was deposited as

unclaimed funds on behalf of:
2. Applicant is entitled to receive the requested funds, has made sufficient
inquiry and has 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):
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.
Applicant is the successor business for the owner of record named in 1, with
authority to 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 establishing chain of ownership and/or assignment.
Applicant is the successor claimant for the owner of record named in 1 as
evidenced by the attached documents establishing transfer of ownership and/or
assignment.
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 other appropriate probate documents substantiating
applicants right to act on behalf of the decedents estate.
Applicant is the representative (i.e., funds locator) of the owner of record
named in 1, as evidenced by the attached notarized, original Power of
Attorney on whose behalf the representative is acting.
None of the above applies. As evidenced by the attached documents, applicant
is entitled to these unclaimed funds because:
ENTER EXPLANATION HERE.
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I declare under penalty of perjury under the laws of the United States of
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America that the foregoing statements and information are true and correct.
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Dated:
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SIGNATURE:
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NAME OF APPLICANT:
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ADDRESS OF APPLICANT:
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PHONE NUMBER OF APPLICANT:
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A NOTARY PUBLIC OR OTHER OFFICER COMPLETING THIS CERTIFICATE
13 VERIFIES ONLY THE IDENTITY OF THE INDIVIDUAL WHO SIGNED THE
DOCUMENT TO WHICH THIS CERTIFICATE IS ATTACHED, AND NOT THE
14 TRUTHFULNESS, ACCURACY, OR VALIDITY OF THAT DOCUMENT.

15
STATE OF CALIFORNIA ss
16 COUNTY OF SAN FRANCISCO

17 On , before me, , Notary Public, personally appeared

, who proved to me on the basis of satisfactory evidence to
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be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that
19 he/she/they executed the same in his/her/their authorized 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 foregoing paragraph
21 is true and correct.

22 WITNESS my hand and official seal.

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_____________________________________________________________
25 SIGNATURE OF NOTARY PUBLIC [SEAL]

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UNITED STATES DISTRICT COURT
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NORTHERN DISTRICT OF CALIFORNIA
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6 )
) Case Number:
7 )
Plaintiff(s), )
8 ) CERTIFICATE OF SERVICE
vs. )
9 )
)
10 )
Defendant(s). )
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)
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I certify that on (date), a true and correct copy of this application for
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payment of unclaimed funds was served by first class United States Mail on:
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Office of the United States
15 Attorney
Northern District of California
16 450 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
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U.S.C. 2042:
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26 Dated:

27 SIGNATURE:

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PRINT NAME:
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3 UNITED STATES DISTRICT COURT

4 NORTHERN DISTRICT OF CALIFORNIA

5
6 )
) Case Number:
7 )
Plaintiff(s), ) [PROPOSED] ORDER FOR
8 ) PAYMENT OF UNCLAIMED FUNDS
vs. )
9 )
)
10 )
Defendant(s). )
11 )
)
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Upon the application of (Applicant), seeking payment of $
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representing funds previously unclaimed by ,
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a party in the above-entitled case, and it appearing from the application and
15 supporting documentation that Applicant is entitled to the unclaimed funds, the
16 Court now orders that the Clerk pay $ to Applicant.

17 IT IS SO ORDERED.
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Dated:
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UNITED STATES DISTRICT/MAGISTRATE JUDGE
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