Security Refund Request Form - State Of New York - Office Of The State Comptroller printable pdf download

110 STATE STREET

THOMAS P. DINAPOLI

ALBANY, NEW YORK, 12236

STATE COMPTROLLER

TATE OF NEW YORK

OFFICE OF THE STATE COMPTROLLER

Office of Unclaimed Funds

Reference Number:_______________

Security Refund Request

Please indicate your payment preference in PART A for the security portion of your claim by initialing the line adjacent to the

option of your choice and provide the requested information when needed. You should then complete PART B and return the

completed form to the address above.

PART A

1)_____

SELL THE SECURITY AND SEND A CHECK FOR THE VALUE

(AVAILABLE ON ALL SECURITY CLAIMS)

I would like to receive the market value for the security portion of my claim. I understand that market value is the cash

value of each security on the date it is approved for payment.

2)_____

WIRE TRANSFER THE SECURITY AS FOLLOWS:

(PLEASE PRINT CLEARLY AND ENTER ALL INFORMATION)

(MUST HAVE AN ACTIVE TRADING / INVESTMENT ACCOUNT WITH A FINANCIAL INSTITUTION TO CHOOSE THIS OPTION)

Name of Broker/Agent ____________________________________________________________________

DTC Participant #

______________________________ Acct.#________________________________

Title of Account

____________________________________________________________________

______)_______________

Broker/Agent Contact _________________________________Telephone #(

3)_____

SEND THE PHYSICAL SECURITY/CERTIFICATE AS FOLLOWS:

(PLEASE PRINT CLEARLY)

(NOT AN OPTION FOR MUTUAL FUND SHARES OR DEMATERIALIZED EQUITY ISSUES)

________________________________________________________________

Mail Security To

________________________________________________________________

4)____

RE-ESTABLISH MY MUTUAL FUND ACCOUNT WITH THE COMPANY THAT CURRENTLY MAINTAINS THE SHARES BEING

CLAIMED.

PART B

EACH OWNER MUST FULLY COMPLETE PART B. YOU MAY ATTACH AN ADDITIONAL PAGE AS NECESSARY.

_____________________________________________________________________

Signature

Taxpayer / Estate ID Number______________________________________________________________

Date of Birth

______________________________________________________

(FOR OPTION 3 AND 4 ONLY)

Date

Daytime Telephone Number

__________________________

(___________)_________________________

NOTE:

BY LAW, THE COMPTROLLER MAY LIQUIDATE A PORTION OF THE SECURITIES RECEIVED. IF THE SECURITY BEING

CLAIMED IS NO LONGER IN OUR INVENTORY, WE WILL REFUND THE CURRENT MARKET VALUE , PLUS ACCRUALS, AS REQUIRED

BY LAW. ALSO, ANY SECURITY TRANSACTION MAY HAVE TAX CONSEQUENCES, SO YOU MAY WANT TO CONSULT WITH A TAX ADVISOR.

PERSONAL PRIVACY PROTECTION LAW - In accordance with the requirements of the New York State Personal Privacy Protection Law,

you are advised that the collection of the information requested in this correspondence is authorized under the provisions of the New York

State Abandoned Property Law and/or the U.S. Internal Revenue Code and the United States Patriot Act. This information is necessary to

determine entitlement to certain unclaimed funds held by the New York State Comptroller and/or to comply with Federal tax reporting

requirements and/or to comply with the identification procedures of the Patriot Act. If you request that a security be issued in your name, the

information provided on this form will be shared with the Office of Unclaimed Funds' broker for the purpose of issuing such security. Your

failure to provide the requested information may prevent the issuance of a security in your name and/or may result in the denial of your claim.

The information provided will be maintained in the Unclaimed Funds Processing System which is under the direction of the Director of

Services of the New York State Office of Unclaimed Funds, 110 State Street, Albany, NY 12236.

Security Refund Request Form - State Of New York - Office Of The State Comptroller

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