WARNING:
To protect against the possibility of others accessing your confidential
information, do not complete these forms on a public workstation.
State of Washington
D
R
Department of Washington
EPARTMENT OF
EVENUE
Unclaimed Property
Unclaimed Property Section
PO Box 47477
Reset This Form
Olympia WA 98504-7477
BUSINESS AFFIDAVIT
RE:
Unclaimed Property Account No.:
In the amount of $
I,
, hereby affirm that I am employed by or am an
Print or Type Name
officer of
and am duly authorized to claim such funds as may be held by you.
And, in the event a superior claim is received and honored by the Department of Revenue, I will hold harmless the
payer of the claim, and will return such funds as received under this claim.
Signature
Title Held
Subscribed and sworn to before me this
day of
,
.
Day
Month
Year
Print This Form
Notary’s Signature
Notary in and for the state of
My commission expires
If the Owner is a Business/Agency/Institution:
1.
Copy the above format onto your company’s letterhead.
Mail all affidavit(s) with the signed
2.
Complete the form.
and dated claim form(s) to:
3.
Have your signature notarized
4.
Return the affidavit with your completed claim form to our office.
State of Washington
Department of Revenue
- OR -
Unclaimed Property Section
If your company does not have letterhead, complete the affidavit and
PO Box 47477
attach a copy of your business license or other documentation identifying
Olympia, WA 98504-7477
your business as a legal entity. Have your signature notarized and return the
affidavit with your completed claim form.
Note: If your company has multiple claims, you may use one affidavit for all. Just state the total number of claims
and the total dollar amount.
For tax assistance visit or call 1-800-647-7706. To inquire about the availability of this document in an
alternate format for the visually impaired, please call (360) 705-6715. Teletype (TTY) users may call 1-800-451-7985.
REV 80 0034e (a) (06/16/05)
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