INSTRUCTIONS FOR HOLDER REQUEST FOR REIMBURSEMENT
PURPOSE
A holder of unclaimed property must complete this form from the State for funds which were paid by the holder and the rightful owner
(or his representative) has been paid for the property.
COMPLETION OF FORM
To ensure accuracy, please fill in as much Holder information as possible. Use a separate Holder Request for Reimbursement for
each report year.
PART I. HOLDER INFORMATION
Enter the name, address, Federal Tax ID number, telephone number and contact person for the holder.
PART II. CLAIM INFORMATION
Enter all data necessary to identify property for which the holder is seeking reimbursement. The identification data entered on this form
must be identical to the information included on the Report of Abandoned and Unclaimed Property submitted to the State by that
holder.
1. Property Code - the universal NAUPA codes for the property claimed as defined on the Summary Sheet of Reported Items or Property
Codes.
2. Account/Reference Number - the identification number of the property which was entered.
3. Owner(s) Name and Address - the full name(s) and address(es) of all the owner(s) as shown on the report. If "unknown" at the time of
report, designate same.
4. If the account was reported in the aggregate, please indicate in the "Account/Reference Number" column.
5. Claimant(s) Name and Address - the full name(s) and address(es) of the person(s) who filed the claim if different than the owner.
6. Date Paid to Claimant or Date Account Reactivated - the date the claim was paid to the owner (or his representative) or when the account
was reactivated by the holder.
7. Amount Paid - the amount paid for the property transmitted by the holder to the State.
8. Total of Reimbursement - the amount expected to be reimbursed to the holder by the State.
PART III. HOLDER CERTIFICATION
This notarized statement must be completed before the State will process the request for reimbursement and make payment. Proof that the
claimant was paid and entitled to the property must be submitted with the request and is subject to audit and review by the State.
Attach a copy of the reimbursement documentation.
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