Cot/st 912 - Unclaimed Property Claim Form & Checklist
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2Control/Claim Number:
Print Form
Unclaimed Property Claim Form & Checklist
Comptroller of Maryland
Compliance Division
Please be sure to
Unclaimed Property Unit, 301 West Preston Street
See attachment for
attach all
instructions
Room 310
necessary
Baltimore, Maryland 21201-2383
documentation.
410-767-1700, or 1-800-782-7383
TDD 410-767-1967
Part A - Claimant Information
X
X
Name of Claimant(s)
Social Security or FEIN Number
X
X
Address of Claimant(s)
Daytime telephone number
X
City, state, zip code
X
Relationship to original owner
Part B - Information on Property claimed
Original owner name:
Social Security or FEIN Number:
Type of property:
Holder name:
Amount of Property:
Part C - Provide the following documents
Copy of your driver's license or other ID
Copy of Social Security Card or other documentation containing social security number
Bank documents (e.g. passbook, bank statement, cancelled check)
Proof of affiliation with:
Letters of Administration,
Small Estate Papers,
True Test Copy of Court Order
Death Certificate(s) for:
Other:
Part D - Affidavit
Under penalties of perjury, I (we) hereby certify that the foregoing information is true and correct. I (we) further certify that I (we)
have not received any property claimed, are entitled to it and know of no other person who claims to be entitled to any portion. I (we)
agree to indemnify the state of Maryland and its officers and employees for any loss of claim whatsoever resulting from the payment
of this claim to me (us).
X
Signature of claimant
Signature of co-claimant
All services provided by the state Comptroller's Office are free. Maryland law provides that you do not have to pay a fee to anyone for
assisting you in recovering any property within 24 months of the date it was turned over to this office. Contracts which provide for a
fee for such claims are unenforceable.
Part E - For office use only
Claim No.: __________
Control No.: __________
Holder No.: __________
Report Year: __________
Received: __________
Amount: $ __________
Interest: $ __________
Total:
$ __________
COT/ST 912 Rev.5/01
UNC PROP 24.01.05/030-03/0902
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