Claim Information Affidavit For Securities Form - Office Of The State Comptroller printable pdf download

REFERENCE NUMBER:___________________

110 STATE STREET

ALBANY, NEW YORK, 12236

STATE OF NEW YORK

OFFICE OF THE STATE COMPTROLLER

Office of Unclaimed Funds

CLAIM INFORMATION AFFIDAVIT FOR SECURITIES

Part A.

(This affidavit must be completed by the Reporting Organization and notarized.)

The information below must come from the final report verification and checklist submitted to this office.

On (1) _______________, _____________, we (2)__________________________________ remitted an abandoned property

report in the amount of (3) $___________________, receipt #___________________ to the Office of Unclaimed Funds, for the

period ending (4)__________________. In this report, on tape sequence or diskette counter number (5)__________________

(OR) page________ and line___________ was the amount (6) $ _______________, representing property type (7)_________

, for bond/ security issue(8) _________________________, bond/coupon number(s)(9)_______________________________ ,

with a face value of (10)$___________________________ per bond/coupon. This security had an early redemption with a due

date of(11) ________________ and a value of(12)$_____________________ per security/bond. The bond was reported in the

name of (13)_______________________________________. (14)______________________________________________is

entitled to the amount of (15) $_____________________.

Preparer’s Signature:________________________________________________

Employer Tax Identification Number:____________________________________

Daytime Telephone Number: (__________)______________________________

Sworn to before me this_________________________________

day of___________________________, 20_________________

Notary Public:_________________________________________

Part B.

(Must be completed by the person entitled to these funds and notarized.)

In consideration of the payment, I/we will save the State Comptroller and the State of New York from any loss due to such pay-

ment. Under penalty of perjury, I certify that the information on this affidavit is true and correct and that the number shown on this

affidavit is the correct Taxpayer Identification Number.

Signature:_________________________________________________________

Present Address ___________________________________________________

Tax Identification Number:____________________________________________

Daytime Telephone Number: (__________)______________________________

Email Address (Optional)_____________________________________________

Sworn to before me this_________________________________

day of___________________________, 20_________________

Notary Public:_________________________________________

PLEASE RETURN ORIGINAL COMPLETED FORM. PHOTO COPIES ARE UNACCEPTABLE.

PERSONAL PRIVACY PROTECTION LAW

n accordance with the Personal Privacy Protection Law, you are advised that the information requested in this correspondence conforms with the provisions of the New

York State Abandoned Property Law. The information is necessary to determine entitlement to certain unclaimed funds held by the New York State Comptroller. Failure to

provide this information may result in denial of the claim. This information will be retained by the Director of Services, Office of Unclaimed Funds, 110 State Street,

Albany, NY 12236. Telephone Number (800) 221-9311.

Claim Information Affidavit For Securities Form - Office Of The State Comptroller

Related Articles

Related forms

Related Categories