Legal Surplus Disclosure Form

LEGAL SURPLUS DISCLOSURE FORM

This Legal Surplus Disclosure Form is executed as of Date: by and between Claimant Name: (Claimant) and Custodian Name: (Custodian).

RECITALS

WHEREAS, a disposition, foreclosure, liquidation or other disposition of assets relating to Case No.: occurred on Date of Disposition: resulting in funds remaining after payment of all secured claims, costs and authorized distributions (the "Surplus Funds");

WHEREAS, Custodian holds or controls the Surplus Funds and requires a written disclosure from any person or entity claiming entitlement to all or a portion of such Surplus Funds; and

WHEREAS, Claimant seeks to identify, disclose and document any interest, claim or entitlement to the Surplus Funds and to make the certifications and indemnities required by Custodian prior to disbursement.

NOW, THEREFORE, in consideration of the mutual promises set forth below, the parties agree as follows:

1. DEFINITIONS

For the purposes of this Form, "Surplus Funds" means the net monetary amount remaining after satisfaction of all liens, costs, fees and authorized distributions related to the disposition identified above. "Claimant" means the person or entity identified above asserting a claim to the Surplus Funds. "Custodian" means the entity holding or administering the Surplus Funds.

2. DISCLOSURE OF SURPLUS

Claimant discloses below all known interests, claims, liens, or entitlements to the Surplus Funds and provides an itemized schedule identifying the source, amount claimed, and basis for each claimed interest.

Schedule A — Itemized Surplus Claims

3. REPRESENTATIONS AND WARRANTIES

Claimant hereby represents and warrants to Custodian as follows: (a) Claimant is the lawful owner of, or has standing to assert, the claims disclosed in Schedule A; (b) the information and documentation provided with this Form are true, complete and correct to the best of Claimant's knowledge; (c) Claimant has not assigned, transferred, or encumbered the asserted rights to the Surplus Funds except as disclosed herein; and (d) Claimant will promptly notify Custodian of any material change in circumstances affecting the Claim.

Entity Type: Individual Corporation Trust Other (specify):

4. CERTIFICATION AND DOCUMENTS

Claimant certifies under penalty of perjury that the statements made in this Form are true and correct. Claimant will provide upon request such documentary evidence as Custodian reasonably requires to substantiate the claim, including but not limited to certified death certificates, probate documents, assignment instruments, powers of attorney, corporate resolutions, or notarized affidavits.

5. RELEASE, INDEMNIFICATION AND CONDITIONS OF DISTRIBUTION

As a condition precedent to any disbursement, Claimant agrees that, upon receipt of any portion of the Surplus Funds, Claimant shall release, hold harmless and indemnify Custodian, its officers, agents and employees from and against any and all claims, demands, liabilities, costs or expenses (including reasonable attorneys’ fees) arising from or related to the distribution, including but not limited to competing claims, subsequent challenges, or third-party assertions, except to the extent caused by Custodian's gross negligence or willful misconduct.

Claimant further acknowledges that Custodian may require additional documentation, an indemnity agreement or escrow of funds prior to distribution and that Custodian may refuse disbursement if claims are contested or if documentation is insufficient.

6. NOTICES

Notices under this Form shall be in writing and deemed given upon delivery if delivered personally or by certified mail to the addresses provided above or to such other address as a party may specify in writing.

7. GOVERNING LAW

This Form shall be governed by and construed in accordance with the substantive laws of the jurisdiction in which the Surplus Funds are held, without regard to conflict of laws principles.

8. ENTIRE AGREEMENT

This Form, together with any attachments and schedules executed concurrently, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior oral or written agreements, understandings, and communications between the parties.

9. SEVERABILITY

If any provision of this Form is held to be invalid or unenforceable, such provision shall be deemed modified to the minimum extent necessary to make it enforceable, and the remaining provisions shall remain in full force and effect.

10. AMENDMENT; WAIVER; COUNTERPARTS

No amendment or waiver of any provision of this Form will be effective except in a writing signed by the party to be bound. Failure to enforce any provision shall not constitute a waiver of the right to enforce that provision in the future. This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

11. ADDITIONAL ACKNOWLEDGMENTS

Claimant acknowledges that Custodian may withhold distribution pending resolution of disputes, completion of due diligence, or receipt of indemnities and that distribution may be apportioned among multiple claimants in accordance with applicable law and verified priority.

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