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Effective July 1, 2012 In re IN THE UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF WYOMING Debtor. Case No. ______________ Chapter VERIFIED PETITION FOR PAYMENT OF UNCLAIMED FUNDS 1. The undersigned _____________________________ [claimant], hereby requests that the court enter an Order Directing Payment of Unclaimed Funds, and in support of the petition states: 2. A check in the amount of $_____________ issued to _____________________________ [owner of record] was tendered to the Clerk of Bankruptcy Court as unclaimed funds.

3. The owner of record did not receive or negotiate the dividend check for the following reason(s): 4. Claimant is entitled to receive the requested funds based upon the following [Check the statement(s) that apply]: G G G G G Claimant is the owner of record of said funds appearing on the records of this court as evidenced by the attached documents including a photocopy of photo identification, such as a driver’s license or passport of the party entitled to the funds, and a social security number. Claimant is the attorney in fact for the owner of record, with authority to receive such funds and is authorized by the attached notarized, original, power of attorney to file this petition on behalf of the original owner of record.

Claimant is the assignee or successor-in-interest to the owner of record, as evidenced by the attached identifying documents. Claimant is an authorized corporate officer (if corporation) or a general partner (if a partnership) and a representative of the owner of record as demonstrated by the attached documentation. Claimant is the personal representative of the owner of record’s estate as evidenced by the attached identifying documents, certified copies of probate documents (letters of administration or probated will), and the decedent’s death certificate. 5.

Claimant has no knowledge that any other party may be entitled to these funds and is not aware of any dispute regarding these funds. 6. The social security or tax identification number of the owner of record is provided to the court on IRS 95 Effective July 1, 2012 Form W-9 Request for Taxpayer Identification Number and Certification. Claimant declares under penalty of perjury, under the laws of the United States of America, that the foregoing is true and correct.

The claimant understands that they may be subject to a fine or imprisonment, or both, if they have knowingly and fraudulently made any false statements in this document. Wherefore, claimant requests that the Court enter an Order Directing Payment of the Unclaimed Funds described above to: Claimant’s Name Address Telephone # DATED: _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ ________________________________ Claimant’s Signature SUBSCRIBED AND SWORN before me this ______ day of _____________________, 20___. ___________________________________ [SEAL] NOTARY PUBLIC in and for the State of ________________________, Residing in ____________________________ County. My commission expires: _______________ CERTIFICATE OF SERVICE Pursuant to 28 U.S.C. § 2042, on ___________________[date], claimant mailed a copy of this completed petition (with all supporting documentation) to: Civil Chief United States Attorney’s Office District of Wyoming P.O. Box 668 Cheyenne, WY 82003 DATED: Claimant’s Signature ____________________________________ 96 Effective July 1, 2012 In re IN THE UNITED STATES BANKRUPTCY COURT FOR THE DISTRICT OF WYOMING Debtor. Case No. ______________ Chapter ORDER DIRECTING PAYMENT OF UNCLAIMED FUNDS The court has considered the Verified Petition for Unclaimed Funds filed by _____________________________ [claimant] requesting payment of unclaimed funds in the amount of $_____________.

The verified petition and the documents attached establish that the claimant is entitled to the unclaimed funds; and the court having verified that the funds are available for distribution to this claimant. Accordingly, IT IS ORDERED that the Verified Petition for Payment of Unclaimed Funds is GRANTED. IT IS FURTHER ORDERED that the Clerk of Court issue a check in the amount of $_____________ payable to _____________________________ [claimant] at the following address:_____________________________________________________________________________ ________________________________________. DATED: __________________________________________ UNITED STATES BANKRUPTCY JUDGE 97 Effective July 1, 2012 Local Bankruptcy Form H Application to Pay Filing Fee in Installments