Form Ador 17-5521 - Indemnity Agreement - Arizona Department Of Revenue

Arizona Department of Revenue • Unclaimed Property Section

INDEMNITY AGREEMENT

Claimant / Successor:

Address:

City:

State:

Zip Code:

Property claiming:

, the undersigned successor in interest of the above

listed property, which is in the legal possession of the State of Arizona (hereinafter referred to as

“the State”), in consideration of receipt of the some or all of the above described property, agree

to indemnify the State and hold it harmless against any and all claims, judgments, decrees, cost,

expenses (including reasonable attorney fees) or any other loss which the State might sustain by

reason of delivering or relinquishing said property to me and by reason of the State’s refusal hereafter

to deliver said property or any part thereof to any other persons or entities.

Subscribed and Afﬁ rmed before me by:

Afﬁ x Seal Here

Notary Signature

Date

Notary in and for the State of

My Commission Expires

ADOR 17-5521 (1/06)

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Parent category: Financial