Form - Affidavit For Reimbursement From Oklahoma State Treasurer'S Office, Unclaimed Property Division, Due To Payment In Error

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AFFIDAVIT FOR REIMBURSEMENT FROM OKLAHOMA STATE
TREASURER’S OFFICE, UNCLAIMED PROPERTY DIVISION,
DUE TO PAYMENT IN ERROR
BY_________________________________________(Company).
I, _________________________, being of lawful age and being first duly
sworn upon oath state as follows:
1.
I am an officer of the above-named Company, having the title of
__________________________________, and am authorized to make this claim
on behalf of the Company.
2.
Monies were reported and/or remitted by the Company to the
Oklahoma State Treasurer, Unclaimed Property Division, in error. Proof of said
reporting and/or remittance are attached hereto.
The Company agrees to indemnify and hold harmless the Oklahoma State
Treasurer’s Office and its employees from any claims resulting from this request
by the Company.
I declare under the penalties of perjury that this claim (including any
accompanying documents and statements) has been examined by me and to the
best of my knowledge and belief is true, correct, complete, and made in good faith,
for unclaimed property held by the Oklahoma State Treasurer’s Office.
______________________________
Printed name:___________________
Title:__________________________
Subscribed and sworn to before the undersigned notary public this ___ day
of ________, 200__.
My commission expires:
__________________________
______________________
Notary public
Commission no._________
[seal]

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