Holder'S Claim For Reimbursement Form

ADVERTISEMENT

HOLDER’S CLAIM FOR REIMBURSEMENT
FOR SCO USE ONLY
C/A# __________________________
MAIL TO:
JOHN CHIANG
REMIT DATE: ___________________
CALIFORNIA STATE CONTROLLER
AMOUNT $______________________
UNCLAIMED PROPERTY DIVISION
RESEARCHER: __________________
P.O. BOX 942850
DATE: __________________________
SACRAMENTO, CA 94250-5873
Note: Requirements and Instructions on Page 2
:
____________________________
REPORT DATE
(DATE SHOWN ON THE ATTACHED UFS-1 FORM)
REPORTED TOTALS:
Dollars: ________________________
Shares: __________
OWNER’S NAME:
_______________________________
STREET ADDRESS:
_______________________________
____________________________
CITY, STATE, ZIP CODE:
OWNER ACCOUNT NUMBER/IDENTIFICATION (SSN): ___________
OWNER PROPERTY REPORTED AMOUNT: Dollars: _____________
Shares: __________
ACCOUNT TYPE: (Circle one) Savings
Checking
Cashier’s Check
Money Order
Other ___________
If Negotiable Instrument, Enter Check Number: _______________
) _________________
REIMBURSEMENT CLAIMED $ _____________________ Securities (# of shares
HOLDER’S USE ONLY
Warrants are paid to the holder shown below:
Holder’s Name: __________________________________________________________________________________________________
Street Address: __________________________________________________________________________________________________
City, State, Zip Code: ______________________________________________________________________________________________
__________________________________________________________________
Holder’s Federal Identification Number (FEIN):
Authorized Agent (If Applicable):
: ______________________________________________________________________________________________
Name
_______________________________________________________________________________________________
Title:
: ________________________________________________________________________________________
Phone number
: ________________________________________________________________________________________
E-mail address
______________________________________________________
Reason for claimed reimbursement:
NOTE: A SEPARATE FORM IS REQUIRED FOR EACH ACCOUNT FOR WHICH REIMBURSEMENT IS CLAIMED
AFFIRMATION AND SIGNATURE
I hereby affirm, under penalty of perjury, that I am an authorized agent of the holder named in this Holder’s Claim for Reimbursement
and duly authorized to make said claim upon the State Controller's Office, as evidenced by the Letter of Authorization accompanying
this claim. The above-named holder hereby agrees to indemnify and hold harmless the State, its officers and employees from any loss
as a result of payment of the amount claimed.
_______________________________________
_______________________________________
Signature:
Date:
SIGNATURES ON THIS FORM MUST BE NOTARIZED ON CLAIMS FOR REIMBURSEMENT OF
$1,000 OR GREATER AND ON ALL CLAIMS FOR SECURITIES
State of California, County of _______________________________
Subscribed and sworn to (or affirmed) before me on this _______ day of _____________________, 20______, by
__________________________________________________, proved to me on the basis of satisfactory evidence to be the
person(s) who appeared before me.
(seal)
SIGNATURE: _______________________________________
HCR-1 Revision 01/08
Page 1 of 2

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2