Holder Request For Reimbursement Form - State Of Arkansas
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2INSTRUCTIONS-HOLDER REQUEST FOR REIMBURSEMENT
PURPOSE:
A holder of unclaimed property must complete this form to request reimbursement of funds which were paid by the
holder to the rightful owner (or his representative) after the funds have been remitted to the Auditor of State.
INSTRUCTIONS:
1. Complete the Holder Request for Reimbursement form in its entirety as detailed below.
2. Provide proof that payment has been made to the claimant.
3. Mail or fax the Holder Request for Reimbursement and proof of payment using the contact information on the
Holder Request for Reimbursement.
4. For questions, please call 501-682-9174.
PART I
Holder Information: Enter the name, address, federal tax ID number, telephone number, contact name, and e-mail
address of the holder.
PART II
Claim information: Enter all data necessary to identify property for which the holder is seeking reimbursement. The
data entered on this form must be identical to the information included on the Report of Abandoned and Unclaimed
Property submitted to the Auditor of State by the holder.
1. Property Code-The property type codes of the property for which you are seeking reimbursement as listed on the
List of Owners of Unclaimed Funds.
2. Account Reference Number-The identification number of the property for which you are seeking reimbursement.
3. Owner’s Name and Address-The full name and address of each reimbursable owner as shown on the report. If
“unknown” at the time of the report, designate same.
4. Claimant’s Name & Address-The full name and address of the person who filed the claim if different from the
owner.
5. Date Paid to Claimant or Account Reactivated-The date the claim was paid to the claimant or when the account
was reactivated by the holder.
6. Amount for Reimbursement-The amount paid to the claimant and transmitted by the holder to the Auditor of
State.
PART III
Holder Certification: This notarized statement must be completed before the Auditor of State will process the
request for reimbursement and make payment. Proof that the claimant was paid and entitled to the property must
be maintained and is subject to audit and review by the Auditor of State.
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