Withdrawal Payee Information - Southern District Court Of West Virginia
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1L R Civ P 67.2 Form (06/08/2017)
UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF WEST VIRGINIA
Withdrawal Payee Information
Attn: Finance Department
CONFIDENTIAL DOCUMENT
Do not file this form on the court’s electronic case filing system.
Under Local C i v i l Rule o f P r o c e d u r e 67.2(b), a party seeking to withdraw funds
from the court registry must file in paper form a completed copy of this form with
the clerk before any funds will be disbursed.
Case Number:
Case Title:
Moving Party:
Full Name of Payee
Address of Payee
Social Security Number or
(No P.O. Boxes)
Employer Identification
Number of Payee
Note: The information collected on this form is provided to the depository institution
pursuant to I.R.S. Ruling 76-50. This information is used for administrative purposes
only and will be kept confidential.
Date:
Attorney or Unrepresented Party
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