Claim Information Affidavit Form - New York State Comptroller
ADVERTISEMENT
1
2THOMAS P. DiNAPOLI
110 STATE STREET
STATE COMPTROLLER
ALBANY, NEW YORK, 12236
STATE OF NEW YORK
OFFICE OF THE STATE COMPTROLLER
OFFICE OF UNCLAIMED FUNDS
CLAIM INFORMATION AFFIDAVIT
REFERENCE NUMBER:
Part A.
This affidavit must be completed by the Reporting Organization and notarized. The information below must come from the final
report verification and checklist submitted to this office.
(1)
(2)
On
_______________, 20__________, we
___________________________________________ remitted abandoned property
(3)
reported in the amount of
$______________________, receipt #________________________ to the Office of Unclaimed Funds, for
(4)
(5)
the period ending
_________________. In this report, on tape sequence or diskette counter number
_______________(OR)
page___________ and line__________ was the following property:
(PLEASE COMPLETE THE APPROPRIATE SECTION – SEE REVERSE SIDE FOR ADDITIONAL DETAILS)
CASH AMOUNTS REPORTED
(6)
(7)
(8)
cash amount
$ _____________,representing property type
________ , reported in the name of
_____________________ .
(9)
(10)
____________________________________is entitled to the amount of
$________________________________________
BOND AMOUNTS REPORTED
(11)
(12)
(13)
the amount
$ ______________, representing property type
__________ , for bond issue
_________________________,
(14)
(15)
bond/coupon number(s)
_________________________,with a face value of
$_______________________ per bond/coupon.
(
16)
(17)
This bond(s) had an early redemption with a due date of
_______________ and a value of
$__________________ per bond.
(18)
(19)
The bond was reported in the name of
________________________________.
______________________is entitled to the
(20)
amount of
$_______________________.
Print Preparer's Name:_________________________________ Preparer’s Signature:_____________________________________
(PLEASE PRINT NAME)
Employer Tax Identification Number:_________________________ Daytime Telephone Number: (_________)___________________
Sworn to before me this__________________
day of___________________, 20__________
Notary Public:__________________________
Part B.
Must be completed by the person entitled to these funds and notarized.
In consideration of the payment, I/we will save the State Comptroller and the State of New York from any loss due to such payment.
Under penalty of perjury, I certify that the information on this affidavit is true and correct and that the number shown on this affidavit is
the correct Taxpayer Identification Number.
Signature:______________________________________
Tax Identification Number:_________________________________
Present Address ___________________________________________________________________________________________
Daytime Telephone Number: (________)___________________
Sworn to before me this__________________
Email Address (Optional)________________________________
day of___________________, 20__________
Notary Public:_________________________
PLEASE RETURN ORIGINAL COMPLETED FORM. PHOTO COPIES ARE UNACCEPTABLE.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial