Unclaimed Property Pending Claim Inquiry Form - Oregon Department Of State Lands (Page 2 of 2) in pdf

Unclaimed Property Pending Claim Inquiry Form - Oregon Department Of State Lands Page 2

UNCLAIMED PROPERTY

PENDING CLAIM INQUIRY FORM

Please use this form only if you are unable to locate your property on the Oregon Department of State Lands (DSL) on-line

owner search application and believe you have funds reported to DSL. See the instructions on how to complete this form.

Items in bold print are required.

Claimant(s) Name:

Current Street Address

City

State

Zip

Daytime Phone :(

)

Cell Phone

(

)

Additional Facts and Explanation

Prior married/ maiden name?

Reported/previous addresses?

Business (Holder) that held/reported the funds:

Explanation of unclaimed funds status: i.e.: date the funds were reported to DSL, amount reported, type of

property and any additional facts (you may use back of form, attach letters and documentation:

I declare under penalty of perjury and/or mail fraud that to the best of my knowledge I am entitled to the assets

of this claim, and agree to indemnify the Oregon Department of State Lands (DSL) and hold it harmless for and

from all claims, loss, costs, damages and expenses that DSL may sustain by turning this asset over to me, or

of its refusal to pay this asset or any part of it to any other person or persons.

Signature

Social Security #

State of ___________ County of ___________Signed or attested before me this _____ day of ____________

By _______________________________________________

Notary Public for: ____________________________________

My Commission Expires: ____________________________

Unclaimed Property Pending Claim Inquiry Form - Oregon Department Of State Lands Page 2