Claim Information Affidavit For Cash Form - Office Of The State Comptroller printable pdf download

REFERENCE NUMBER:___________________

110 STATE STREET

ALBANY, NEW YORK, 12236

STATE OF NEW YORK

OFFICE OF THE STATE COMPTROLLER

Office of Unclaimed Funds

CLAIM INFORMATION AFFIDAVIT FOR CASH

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.

On (1) _______________, 20__________, we (2)__________________________________ remitted abandoned property

report in the amount of (3) $___________________, receipt #_________________ to the Office of Unclaimed Funds, for

the period ending (4)____________________________________. In this report, on tape sequence or diskette counter

number (5)___________(OR) page___________ and line__________ was the amount (6) $ ______________________,

representing property type (7)_____________ , reported in the name of (8)__________________________________ .

(9)______________________________________is entitled to the amount of (10) $______________________________

Print Preparer's Name:_______________________________________________

(PLEASE PRINT NAME)

Preparer’s Signature:________________________________________________

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:_________________________________________________________

Present Address ___________________________________________________

Tax Identification Number:____________________________________________

Daytime Telephone Number: (__________)______________________________

Email Address (Optional)_____________________________________________

Sworn to before me this_________________________________

day of___________________________, 20_________________

Notary Public:_________________________________________

PLEASE RETURN ORIGINAL COMPLETED FORM. PHOTO COPIES ARE UNACCEPTABLE.

PERSONAL PRIVACY PROTECTION LAW

In accordance with the Personal Privacy Protection Law, you are advised that the information requested in this correspondence conforms with

the provisions of the New York State Abandoned Property Law. The information is necessary to determine entitlement to certain unclaimed

funds held by the New York State Comptroller. Failure to provide this information may result in denial of the claim. This information will be

retained by the Director of Services, Office of Unclaimed Funds, 110 State Street, Albany, NY 12236. Telephone Number (800) 221-9311.

Claim Information Affidavit For Cash Form - Office Of The State Comptroller