Looking for a Claim Form Templates? Download it for free!

Claim Form Instructions

Box 1 – Claimant Name: Print your name and provide a copy of your current driver’s license or

other legal photo identification. If your name has changed, please provide proof of the name change

i.e. copy of marriage certificate, divorce decree, etc.

If you are inquiring on behalf of a business, print the business name.

Box 2 and 3 – Claimant’s Address: Print current mailing and/or street address. If this is a post office

box please provide on the second line your street address i.e. Route 3 Sugar Grove Lane.

Box 4 – Claimant Phone Number and email address: Print primary contact phone number and

email address if applicable.

Box 5 – Claimant Social Security Number (SSN) or Federal Employer Identification Number

(FEIN): If the property is the name of an individual, claimant must provide SSN on the claim form

and copy of social security card or documentation with owner’s name and SSN.

If the property is in the name of a business, claimant must provide proof of business’s FEIN in the

form of a recent tax document, IRS 941 form, Workers Compensation Insurance documents or

notification of FEIN from the IRS. Provide a valid identification of the claimant i.e. unexpired photo

identification and/or employee id signing the claim form.

In addition to the proof of FEIN one of the following is required:

A resolution or agreement indicating claimant’s authority to claim the property on behalf of the

business, or

Recent federal income tax filing or copy of a Secretary of State’s office filing, indicating the level

of authority of the claimant signing the claim form. The filing must show that the claimant

signing the claim form has authorization to claim this account on behalf of the company.

Box 6 – Are you the Owner of the Property? If you are the owner of the property, check “Yes”. If

you checked “No”, please provide the following:

A copy of the Power of Attorney or other documentation showing your authority to file on their

behalf. Also, send a copy of the owner’s identification that discloses their SSN and other proof of

identification i.e. insurance card or voter’s registration card. If the owner is a minor, provide a

copy of their state birth certificate and SSN.

Box 7 – Owner Deceased:

If you are claiming for a deceased owner and an estate is open, check “open”, then print name of

estate administrator or executrix. Only the Administrator or Executrix may claim for an estate;

payments are made to an “Estate in care of the Administrator or Executrix.”

If an estate is closed, check “closed” and send an Estate Declaration Form with your claim.

For both open and closed estates provide a copy of the death certificate, documentation of SSN of

the owner if it is not on the death certificate, copy of the Will document, if applicable and a

completed W-9 form. If there is a surviving spouse noted on the death certificate also provide a

copy of their SSN and unexpired driver’s license. Note: If the claimant is the surviving spouse the

Estate Declaration Form is not required.

For those that complete a W-9 form the 1099 forms generated annually will be completed with

the claimants’ SSN and signatures that are provided with their claim. For example, if there are

four claimants and only one W-9 form completed then that claimant will be responsible for the

tax consequences for the total amount of the applicable property. See the Federal Privacy Notice

Act on front of Claim Form page with applicable property types.

If you cannot provide documentation as requested, please attach a letter explaining why you are

entitled to this property or any special circumstances that may apply to this claim.

Revised 4/2008

Claim Form And Instructions - Office Of The State Treasurer John D. Perdue, State Treasurer Page 2

Related Articles

Related forms

Related Categories