Holder'S Claim For Reimbursement Form (Page 2 of 2) in pdf

REQUIREMENTS FOR HOLDER’S CLAIM FOR REIMBURSEMENT

When completing the claim form, please type or print legibly in ink. Claims that are illegible will be returned.

II.

Claims for reimbursement must be made using the Holder’s Claim for Reimbursement, Form HCR-1 (Revision 7/04). The form

can be downloaded from the California State Controller’s website at Modifications of the Holder’s Claim for

Reimbursement Form will not be accepted.

III. Reimbursements will be made to the holder only.

IV. A copy of the Holder Face Sheet, Form UFS-1, filed with the holder’s report in which the claimed property is reported should

accompany all reimbursement claims. A copy of the report showing the owner’s account will also facilitate reimbursement.

A Letter of Authorization must accompany ALL claims for reimbursement. The letter must be on the claiming holder’s letterhead

and must contain the name of each individual authorized to claim property from the Controller’s Office on behalf of the holder. On

request, the Letter of Authorization will be maintained on file.

VI. Proof of payment to the owner and proof of ownership is required on all holder’s claims for reimbursement. Proof of payment may

include: a copy of the payment made to the owner or heir; documentation showing that the owner’s account has been re-

established (holders may provide a system-generated document showing reactivation of an account); a copy of the stock

certificates or book entry (in cases involving stocks or mutual funds); or documentation showing payment via electronic funds

transfer. When reimbursement is sought for payment of a negotiable instrument (including check, money order, cashier’s check,

or traveler’s check),the holder must include proof that the instrument was duly presented to the holder and payment was made to

the person who appeared to be entitled to payment.

VII. Proof of ownership may include: copies of identification of the owner or heir; a copy of the owner’s Social Security

card; or documentation showing association with the institution.

INSTRUCTIONS FOR COMPLETING FORM HCR-1

Report Date: Enter the date from the UFS-1 Form filed with the Unclaimed Property report.

Reported Totals: Enter the total dollars and/or shares remitted on the report.

Name & Address: Enter the owner’s name and address as shown on the Unclaimed Property Report.

Owner Acct Number: Enter the owner’s Social Security number (SSN) or the holder’s account number if the SSN was not reported.

Owner Property: Enter total dollars and/or shares reported for the owner for whom reimbursement is requested.

Reported Amount:

Account Type: Enter the type of account held by owner (savings, checking, cashier’s check, money order, or other, i.e. securities).

Negotiable: Enter the check number for the cashier’s check, money order, or traveler’s check.

Instrument Number:

Reimbursement: Enter the amount claimed for reimbursement. This amount must match the amount of property reported to the

Controller.

Claimed:

Securities: FOR SECURITIES ONLY. Enter the number of shares requested for customer reimbursement. The number of shares

must match the number of shares reported.

Holder’s Name: Enter the name, street address, city, state, and zip code of the holder exactly as shown on the Form UFS-1

submitted with the claim.

Address:

Holder’s FEIN: Enter the holder’s federal identification number.

Authorized Agent: Note: An authorized agent has the authority to claim reimbursements for the holder.

Name: Enter the name of the authorized agent signing the claim.

Title: Enter the title of the authorized agent signing the claim (i.e., Bank Official, CEO).

Phone Number: Enter the telephone number and extension, if any, of the authorized agent.

E-mail Address: Enter the e-mail address, if any, of the authorized agent.

Reason: Enter an explanation for the claimed reimbursement (i.e., erroneous escheatment or overpayment).

Affirmation: The authorized agent named in the claim must sign and date the affirmation.

Signature: Unsigned claims will be returned.

Notarization: All reimbursement claims involving securities, regardless of amount, require notarization. Non-securities claims must be

notarized if the amount claimed is $1,000 or greater.

HCR-1 Revision 01/08

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Holder'S Claim For Reimbursement Form Page 2

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