State of West Virginia
Holder Claim Form
John D. Perdue, Treasurer
Claim and Affidavit for Recovery of Property
Please complete each section.
Holder
Owner
Name__________________________________
Name__________________________________________
Address________________________________
Address________________________________________
________________________________
________________________________________
(City)
(State)
(Zip)
(City)
(State)
(Zip)
Phone Number __________________________
Social Security Number____________________
Report Date_________ Sheet Number________
Please mail form to:
Property Description______________________
Office of State Treasurer
Unclaimed Property Division
_______________________________________
Post Office Box 4228Charleston, WV 25364
Property Type___________________________
If you have questions:
If interest bearing or security related please complete
Phone Number (800) 642-8687
a W-9 form.
Please allow approximately 60 to 90 days for your claim to be
Amount________________________________
processed
Note: if the person signing is not the holder contact please send
in a photo id.
Claim is hereby filed for unclaimed property held by the Treasurer of the State of West Virginia in
accordance with the Uniform Unclaimed Property Act, WV Code § 36-8-1, et seq.
State of _______________
County of _____________
I, ______________________ (individual representing the business), first being duly
sworn under penalty of perjury hereby affirm that I am authorized to make this claim on
behalf of the holder named above (the “Holder”). I further certify that the Holder has
paid the property described above to the person reasonably appearing to be entitled to
payment, and that the Holder is therefore entitled to reimbursement as provided in West
Virginia Code '36-8-10.
Representative Signature_________________________
Subscribed and sworn to before me this ______________ day of ___________________ My
commission expires___________________.
Notary Public Signature______________________________
Notary
Stamp
Revised 7-2014