APPLICATION FOR UNCLAIMED FUNDS
1. Claim Information
Application is hereby made for disbursement of the following previously unclaimed funds on deposit with the
court for the benefit of the claimant named below.
(at time claim was made)
*Provide documentation that Claimant resided or did business at this address.
(if different from above)
Last 4 digits of Claimant’s
SSN or Complete EIN
2. Applicant Information
The applicant is:
The individual claimant named above. Photo identification is attached.
An individual authorized to act on behalf of the corporation, partnership, limited
liability company, or other artificial entity named above. Documentation showing
authority to make this application is attached.
The legal representative of the claimant named above. An original, notarized power
of attorney is attached, or, if the claimant is deceased, a certified copy of a letter of
administration or probated will is attached.
The successor in interest to the claimant named above. Documentation showing
entitlement to the funds through amendment, merger, or dissolution is attached.
UNITED STATES BANKRUPTCY COURT
DISTRICT OF HAWAII
1132 Bishop Street, Suite 250
Honolulu, Hawaii 96813
3. Service on United States Attorney
The undersigned understands that a copy of this application and supporting documentation must be sent to
the United States Attorney at the following address:
Office of the United States Attorney
District of Hawaii
300 Ala Moana Boulevard, Room 6100