Power of Attorney form

(Name and address of firm submitting claim)

Power of Attorney — To Recover Unclaimed Dividends

1.  (Name of Individual/Company named as Power of Attorney) has determined that an unclaimed dividend from the estate of (Name of insolvent and estate number), for the sum of $ , was sent to the Receiver General for Canada for the following payee:
   (Name and address of payee).
2.  (Name of Individual/Company named as Power of Attorney) is hereby appointed as attorney for  (Name of creditor) for the single purpose of collecting this account on behalf of the payee.
3. The Receiver General for Canada is instructed to forward a cheque for the amount of the dividend, payable to  (Name of Power of Attorney) in trust.
4. Upon receipt of the funds from the Receiver General for Canada,
   (Name of Power of Attorney) will immediately forward the funds to the creditor, minus the agreed upon fee.