Affidavit And Agreement Supporting Claim By Surviving Joint Owner Form

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Affidavit and Agreement Supporting
Claim by Surviving Joint Owner
I, the undersigned Claimant, 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:
D
O
’
I
:
ECEASED
WNER
S
NFORMATION
N
D
O
: _____________________________________________________________
AME OF
ECEASED
WNER
D
’
SSN: ______________________________________________________________________
ECEDENT
S
D
’ D
B
: _________________ D
’
D
D
: ___________________
ECEDENT
ATE OF
IRTH
ECEDENT
S
ATE OF
EATH
P
C
:
ROPERTY
LAIMED
The above-named Deceased Owner and I were the rightful joint owners of property that the Office of the
State Treasurer associates with the following property identification number(s): _____________________.
C
’
T
C
A
:
LAIMANT
S CAPACITY
O
LAIM AND ENTER
GREEMENT
I am entitled to claim this property as the sole surviving joint owner. My claim for the property either
accompanies this A
or has been previously submitted to the Office of the State Treasurer.
FFIDAVIT
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.
Claimant’s Signature: _________________________________________________
Date: ____________
Claimant’s Name (printed): _____________________________________________
Personally appeared before me the said Claimant 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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