Ador 17-2022 Holder Reimbursement Request Form

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Arizona Department of Revenue • Unclaimed Property Section
HOLDER REIMBURSEMENT REQUEST FORM
Date Paid to Owner or Reinstated:
Report Year:
Remitted Amount:
M M
M M
/ D D
D D
/ Y Y Y Y
Y Y Y Y
Y Y Y Y
Y Y Y Y
$
Reported Name(s): If aggregate, specify.
Account Number:
Proof of payment to customer/rightful owner must accompany this request.
AUTHORIZATION AND INDEMNITY AGREEMENT
As a duly authorized offi cer of the reporting institution (holder) ________________________________, Federal Tax
ID No. ___________________, I depose and swear under oath that I am authorized to make this affi davit. Based
upon personal knowledge, the information provided by the reporting institution (holder) to substantiate payment to the
owner or reinstatement of the remitted account is true and correct. By demonstrating that the owner, or his/her personal
representative was paid or reinstated, I hereby certify this claim for reimbursement is valid and just. Upon payment by
the Arizona Department of Revenue of the reimbursement described above, the reporting institution (holder), herein
named, agrees to indemnify and hold harmless the State of Arizona, its employees and agents from any and all liability,
claims, demands, losses, suits, or actions, arising from or related to any other party who hereafter asserts or attempts
to establish right to payment of the above described funds to the extent of the value of the property so paid or delivered.
By
Street Address
Title
City, State, Zip
(
)
Date
Telephone
Please mail completed form and documentation to:
Arizona Department of Revenue
Unclaimed Property
PO Box 29026
Phoenix, AZ 85038-9026
FOR DOR USE ONLY
PID No.
Claim No.
Date Processed
By
By
APPROVED
APPROVED
DENIED
DENIED
ADOR 17-2022 (8/03)
Previous ADOR 11-2022

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