Cash Dash Claim Form - Illinois State Treasurer
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1
2
3ALEXI GIANNOULIAS
Illinois State Treasurer
C
DASH C
F
ASH
LAIM
ORM
(To be used only if you have identified property on the Cash DASH list. See pages 2-3 for instructions to complete this form.)
Over $100
$10-$100
Under $10
?
Account Information
1. Name as it appears on list/Company Name
2. Address as listed
3. Social Security Number/FEIN
Individual Submitting Claim
4. Last Name
5. First Name
6. Middle Initial
7. Current Mailing Address
8. City
9. State
10. Zip Code
11. Daytime Telephone Number
12. Social Security Number/FEIN
My relationship to the owner of the property
13.
:
I am the owner of the property
Heir where there has been no probate
Guardian or other representative of the owner
Power of Attorney
Executor or administrator for the owner
Other – explain_______________________________
The following must be included with this form:
1.
Clear copy of documentation showing the social security number of the
claimant, and
2.
Proof of the original owner’s address as listed in box number 2 above
3.
Claimant must have signature notarized (
not required if amount less than $100)
4.
Additional documentation, as applicable, described in the instructions on pages
2 and 3.
The named claimant hereby certifies that this claim for property presumed abandoned is valid and just, that all statements herein
are true and correct, and that upon payment of this claim, said claimant will indemnify and hold harmless the State of Illinois, its
officers and employees, from any other valid claims to the said property.
Claimant swears and affirms that they are the proper claimant in the foregoing claim and that the above statements are true to the
best of their knowledge.
SUBSCRIBED AND SWORN TO BEFORE ME BY
SIGNATURE OF CLAIMANT(S):
____________________________________ (Claimant(s))
X_______________________________________
X_______________________________________
THIS ______ DAY OF ___________________, 20_____
_______________________________________________
Mail completed form to:
Signature of Notary Public
County / State
Illinois State Treasurer’s Office
My Commission Expires: __________________________
Unclaimed Property Division
P.O. Box 19495
Notary Seal:
Springfield, IL 62794 9495
Print
Reset
Rev. 2/07
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