Inquiry/claim Form - Virginia Department Of The Treasury
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1Approved
User
Date
Department of the Treasury
1st Level
Division of Unclaimed Property
l
2nd Leve
Inquiry/Claim Form
P O Box 2485 Richmond, VA 23218-2485
@trs
rd
3
Level
1.
Please direct correspondence to me
:
JOSEPH A HOLLEY
___________________________
Name:
email:
113 FORKADEER LANE
ROCKY MOUNT, VA 24151-5448
Address:
Telephone _____________________________
2. The name on the accounts I am searching for:
_____________________________________________
_______________________________________
_______________________________
(Former names, different surnames, spouse, if applicable)
(Social Security Number)
Owner Information: Please enter the information requested in section #2. Personal information submitted on
this form is kept confidential and is NOT shared with any other State Agency, business or individual.
3.
______________
The account number, if this name was listed in the newspaper:
4.
Previous mailing addresses for the name(s) in Section #2
:
(for additional addresses, please use back of this
page)
1. ______________________________________
_______________ _____ _________
2. ______________________________________
_______________ _____ _________
3. ______________________________________
_______________ _____ _________
House/Building # and Street name or Box #
City
State
ZIP
5.
In order to process my claim, I am enclosing copies of the ALL of the following
:
Check each box to indicate you have done so.
Driver’s License/Photo ID
Social Security Card OR Tax document with your Social Security Number on it
6.
Please read and sign the following affidavit
:
Under the penalty of perjury, I certify that I am the claimant above; I have not received the money or property
involved in this claim; I accept fiduciary responsibility for the distribution of these assets, if appropriate, and do
not know of anyone else with a superior claim to these assets. I agree to return the property to the State
Treasurer if it is later determined that it belongs to someone else, and to reimburse the State for any loss
resulting in payment of this claim to me. Any and all accounts that I am entitled to claim based on the
documentation I have provided are hereby incorporated into this request.
_____________________________________
______________________________
Signature
Date
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