Claim Form - Virginia Department Of The Treasury
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1Approved
User
Date
Department of the Treasury
1st Level
Division of Unclaimed Property
l
2nd Leve
Claim Form
P O Box 2485 Richmond, VA 23218-2485
rd
3
Level
Owner Information
Please enter the requested information. Personal information submitted on this
form is kept confidential and is NOT shared with any other State Agency, business or individual.
1. The name as listed in this paper: _____________________________________________
_______________________________________
_______________________________
(Former names, different surnames, spouse, if applicable)
(SSN of person or Federal Tax Id of organization)
2.
______________
The account number listed
3
.
Please select one of the following:
I am the person listed in Part I or authorized to represent the company
The person listed in Part 1 is deceased
The person listed in Part 1is my: ____ spouse ____child____ sibling ____parent ____other
4.
Please direct correspondence to me:
______________________________________________________________________
Name
_____________________________________________________________________
Address
________________________________
email:
Telephone _________________________________
5.
Previous mailing addresses for the name in Part I: (for additional address, please use back of this page)
1. ______________________________________
_______________ _____ _________
2. ______________________________________
_______________ _____ _________
3. ______________________________________
_______________ _____ _________
House/Building # and Street name or Box #
City
State
ZIP
6.
In order to process my claim, I am enclosing copies of both:
my photo ID (such as driver’s license) AND
a document with my Social Security Number on it (tax form, SS
card or similar document). We will accept fax copies of your personal identification documents at 804-692-0576, but your
claim cannot be processed unless you return this Form with your original signature by mail to the address in the top left
corner of this form.
7.
Please read and sign the following affidavit:
Under the penalty of perjury, I certify that I am the claimant above; I have not received the money or property
involved in this claim; I accept fiduciary responsibility for the distribution of these assets, if appropriate, and do
not know of anyone else with a superior claim to these assets. I agree to return the property to the State
Treasurer if it is later determined that it belongs to someone else, and to reimburse the State for any loss
resulting in payment of this claim to me. Any and all accounts that I am entitled to claim based on the
documentation I have provided are hereby incorporated into this request.
___________________________________________
______________________________
Signature
Date
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