Corporate Claim Reimbursement Form
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1
2T
P
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110 S
S
HOMAS
.
iNAPOLI
TATE
TREET
S
C
A
N
Y
TATE
OMPTROLLER
LBANY,
EW
ORK 12236
S
TATE OF NEW YORK
OFFICE OF THE STATE COMPTROLLER
Office of Unclaimed Funds
Corporate Claim Reimbursement Form
Name of Reporting Organization
Contact Name
Tax ID Number
Address
City
State
Zip
Telephone number
Email Address
Owner Name
Address of Record
Amount
Year
(Please identify if it's an unknown owner)
(If an unknown owner, please identify dormancy date)
(If in an aggregate,
Reported
please specify
aggregate total and
amount due owner)
1
2
3
4
Total Amount of Report
Property ID Number
Property Type
5
6
7
Payee name and current address
Payee Tax ID Number
8
9
10. If the property was reported in error, please explain in the area provided below and submit proof of same.
11. If the owner has already been paid, please see instructions on next page.
12. “In consideration of the payment of this claim, I/we will reimburse to the Office of the State Comptroller and the
State of New York the amount due to any additional persons who are entitled to these funds. Under penalty of
perjury, I certify that the information on this affidavit is true and correct.”
Signature of Officer:
Sworn to before me this ______ day of _________, 20___
Notary Public
_______________________
Date
**PLEASE RETURN THIS COMPLETED FORM TO THE ADDRESS ABOVE**
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Parent category: Business