CLAIM REQUEST FORM
Name:
____________________________________________________
Address:
____________________________________________________
City, State, and Zip Code:
____________________________________________________
Owner's Name Reported As:
____________________________________________________
Please provide the following information; without it, we can’t process your claim request.
•
Your SSN or EIN.
•
Your signature on the Claim Request Form.
•
A clear copy of your photo ID.
•
Your daytime telephone number.
•
A copy of the death certificate if the owner is deceased.
Provide your Social Security Number (SSN) or the Employer Identification Number (EIN) of your business or
organization. If you are not the owner of the account, also provide the owner’s SSN.
________________________________
________________________________
Your SSN or EIN
and/or
Owner’s SSN if not Claimant
I declare that I have been examined this form and accompanying documents and, to the best of my knowledge
and belief, they are true, correct and complete.
_____________________________________________
_________________________
Your Signature
Date
Daytime Telephone Number: (_______) ___________________________
How did you find out that your name was on Idaho’s Unclaimed Property list?
Relative/Friend
Internet
Television
Special Events
Newspaper
Idaho State Tax Commission • Unclaimed Property Program • 800 Park Blvd., Plaza IV • PO Box 70012 • Boise ID 83707-0112
(208) 334-7627 • Fax (208) 334-5366 • Hearing Impaired TDD 1-800-377-3529 • tax.idaho.gov • Equal Opportunity Employer