United States Bankruptcy Court For The Western District Of Oklahoma Page 4
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5UNITED STATES BANKRUPTCY COURT
FOR THE WESTERN DISTRICT OF OKLAHOMA
IN RE:
)
)
Case No. _____-__________-_____
)
)
Chapter ________
Debtor(s).
)
AFFIDAVIT OF CREDITOR/CLAIMANT
State of ______________________ )
Tax ID or Last 4 numbers of SSN:
: ss
___________________________
County of ____________________ )
I. ___________________________________, the undersigned creditor/claimant in the
above referenced case, being first duly sworn upon oath, state as follows:
1. ___________________________________________________________________
has been granted a power of attorney by me to submit Application for Payment from Unclaimed
Funds seeking payment of claim number ________, in the amount of $______________, due
and owing to me as a creditor/claimant in the above-referenced bankruptcy case.
2.
My name, position with the company (if applicable), address and telephone
number are as follows:
___________________________________________
___________________________________________
___________________________________________
3.
If other than individual: Substantiate creditor’s right to claim, including but not
limited to, documents relating to sale of company, i.e., purchase agreements and/or stipulation by
prior and new owner as to right of ownership of funds. Attach certified copies of all necessary
documentation.
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