Corporate Claim Reimbursement Form (Page 2 of 2) in pdf

INSTRUCTIONS TO COMPLETE FORM

Owner Name:

The name of the owner of record as it appears on the Final Abandoned Property Report. If the

property reported is in an aggregate or as an unknown owner, please write ‘Unknown’.

Owner Address:

The address of record as it appears on the Final Abandoned Property Report. If the property is

reported as an unknown owner, please provide us with the dormancy date of the property.

Amount:

The total dollar amount reported for this property. If the property is reported in an aggregate, please

provide us with the total amount of the aggregate and how much the owner is entitled to.

Year Reported:

The date found on the Verification and Checklist submitted with the final report.

Total Amount of Report:

The grand total for the entire report of the total amount of the check submitted for payment with this

report.

Property ID Number:

The check number, account number, policy number, certificate number or other number that was

used to identify the property on the Final Abandoned Property Report.

Property Type:

The property type is the code used to describe an item on the Abandoned Property Report. A list of

these codes can be found on the back of the Verification and Checklist.

Payee Name and Current Address:

The name and address of the person/entity your organization made payment to.

Payee Tax ID Number:

Tax Identification Number of the person/entity your organization made payment to.

10. Reported in Error:

If this property was reported in error, please give a brief explanation of how this error occurred.

We also require proof of the error. Such proof may be a written communication from your customer

reflecting a date that would have reactivated the property prior to escheatment or a copy of any

ledger or journal entry showing how the erroneous escheatment occurred along with an explanation

of the transaction.

11. Reimbursement - Owner has already been paid:

Submit a copy of both sides of the canceled check that was issued in payment to your customer.

If a check was not issued in payment to the customer, please submit other documentation clearly

showing payment to the customer.

12. Signature:

An appropriate officer of your organization must sign the form, and the signature must be notarized.

Corporate Claim Reimbursement Form Page 2