Unclaimed Property Holder Claim Form - Virginia Department Of The Treasury (Page 2 of 2) in pdf

Unclaimed Property Holder Claim Form - Virginia Department Of The Treasury Page 2

Unclaimed Property Holder Claim Form

Filing Instruction

THE HOLDER CLAIM FORM MUST BE FULLY COMPLETED BEFORE ANY CLAIM MAY BE

PAID.

Section A: Provide the name of a contact person and telephone number in case there are any questions about the

claim.

Section B: Provide the name and address of the holder as it appeared on the most recent report. The Federal

I.D. number must also be provided.

Section C: Provide information about the REPORTED OWNER and CO-OWNER if applicable. On these two

lines, indicate the name and address in which the account was originally reported.

Section D: Identify the property type being claimed (i.e. savings, checking, unpaid wages, unpaid dividends,

deposit refund, etc.) and information concerning the report and remittance.

Section E: Provide a copy of the check issued in payment to the owner (or proof that the owner’s account was

reactivated by your organization) with this completed claim form. If the account was reported in error, please

explain the error in one or two sentences.

Section F: Sign the Affidavit according to the instructions.

Note: If requesting reimbursement for an account reported in the aggregate, a complete list of the aggregate

account detail must be submitted if you did not provide this information with the original report

Unclaimed Property Holder Claim Form - Virginia Department Of The Treasury Page 2