Affidavit And Agreement Supporting Claim By Authorized Representative For Another Person Form

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Affidavit and Agreement Supporting Claim by
Authorized Representative for another Person
I, the undersigned Claiming Agent, as authorized representative for the below-identified person entitled to
claim certain unclaimed property now held in custody by the Office of the State Treasurer, said property being
specifically referenced below by property identification number(s), after being duly sworn, do hereby affirm as
follows:
O
I
:
WNER
S
NFORMATION
N
L
O
: _______________________________________________________________
AME OF
ISTED
WNER
M
: _____________________________________________________________
A
(
)
AILING
DDRESS
CURRENT
______________________________________________________________________________________
SSN: ______________________________ T
: _______________________________________
ELEPHONE
D
B
: ________________________________________________________________________
ATE OF
IRTH
P
C
: The above-named Owner is the rightful owner of property that the Office of the State
ROPERTY
LAIMED
Treasurer associates with the following property identification number(s): ________________________________.
C
T
C
A
:
LAIMING AGENT
S CAPACITY
O
LAIM AND ENTER
GREEMENT
I am authorized to place this claim and enter the below-stated A
because:
GREEMENT
I am the licensed Attorney representing the Owner and my Bar Association Number is: ________________
I hold a valid Power of Attorney given to me by the Owner.
I am the court-appointed Guardian of the Owner.
I am the court-appointed Conservator of the Owner.
I am the duly appointed Trustee for the Owner.
Other: (Please explain) ___________________________________________________________________
_________________________________________________________________________________________
A
: Claimant agrees to indemnify and hold harmless the Office of the State Treasurer against any
GREEMENT
superior claim(s) made on the above-claimed property.
Claiming Agent’s Signature: _________________________________________________
Date: ____________
Claiming Agent’s Name (printed) _________________________________________________________________
Personally appeared before me the said Claiming Agent and affirmed the above-stated facts as true and correct
based upon his/her own personal knowledge.
County _________________________
State __________________
Subscribed and sworn before me on: _______________________ (date)
(seal)
Notary Public: ______________________________________________
Print Name:
My commission expires: ________________:
R
: 03/20/06(DGL)
EVISED

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