UNITED STATES BANKRUPTCY COURT

EASTERN DISTRICT OF MISSOURI

In Re:	)

)	Case No.

)

)	Chapter

)

)	AFFIDAVIT OF CREDITOR

)

)

Debtor(s)	)

I, the undersigned creditor in the above referenced case declare as follows:

1.	(Name and Address)

has been granted a power of attorney by me to submit an Application For Payment From Unclaimed Funds seeking payment of claim number (if no claim was filed write "scheduled" in blank space) in the amount of $ due and owing to me as a creditor in the above referenced bankruptcy case.

2.	My name, position with company (if applicable), address and telephone number are as follows:

3.	Creditor History: 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.

4.	I (or the company which I represent) have neither previously received remittance for this claim nor have contracted with any other party other than the person named in item one above to recover these funds.

I hereby certify that the foregoing statements are true and correct to the best of my knowledge and belief.

Date	Creditor

S.S. # (last 4 digits)

Business ID # (last 4 digits)

Sworn to and Subscribed before me this day of , 20 .

NOTARY PUBLIC, AT LARGE

STATE OF