STATE OF COLORADO - TREASURERS OFFICE
Unclaimed Property Division
1580 Logan St Ste 500, Denver, CO 80203-1941
303-866-6070 greatcopayback@state.co.us
HOLDER REQUEST FOR REIMBURSEMENT
STANDARDIZED HOLDER CLAIM FORM
For funds paid to the Department for Report Year
ending _________ Date remitted: ____________
PART I: HOLDER INFORMATION: (See instructions for claim completion)
Name of Holder:
Address:
City:
State:
Zip:
Tax ID#:
Telephone No.:
Contact:
(
)
PART II: CLAIM INFORMATION
Property
Acct Reference No.
Owner’s Name
Owner’s Address
Claimant’s Name & Address
Date Pd to Owner or
Code
(If Aggregate-Specify)
exactly as on report
as listed on report
If different than Owner
Acct. Reactivated
Amt Paid
$0.00
Total Request for Reimbursement $ ________________
Include documentation of reimbursement. If amount was remitted in error - please explain:
PART III: HOLDER CERTIFICATION
I, _____________________________ a duly authorized representative of the holder listed above, do hereby
Sworn to and subscribed before me this
have been
certify that the above listed funds, or other property which was listed in the report filed by the holder
______ day of ____________ 20___
paid
to the rightful owner(s) or their appointed representative. I agree, upon payment of the above described
property to indemnify the state and hold it harmless from all claims and loss, demands, costs, and other expenses
Notary: ___________________________
which the State may sustain by reason of turning over property to the holder and by reason further of its refusal
My commission expires: ______________
to pay the property to any other person or persons:
Name of Representative (type or print) _______________________________________________________
Signature of Holder Representative _______________________________________ Date _____________
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