Form Affidavit For Reimbursement From Oklahoma State Treasurer'S Office, Unclaimed Property Division printable pdf download

Form Affidavit For Reimbursement From Oklahoma State Treasurer'S Office, Unclaimed Property Division

AFFIDAVIT FOR REIMBURSEMENT FROM OKLAHOMA STATE

TREASURER'S OFFICE, UNCLAIMED PROPERTY DIVISION,

BY___________ ______________________________ (Company)

PURSUANT TO 60 O.S. '664 AND OAC 735:80-7-5

I, _____________________________________, being of lawful age and

being first duly sworn upon oath state as follows:

I am an officer of the Company and am authorized to make this claim

for reimbursement on behalf of the Company.

Monies were reported and remitted by the Company to the Oklahoma

State Treasurer, Unclaimed Property Division. Proof of reporting and remittance

are attached.

Payment of these previously reported and remitted Monies, was made

to _____________________________, who was determined by the Company to be

the Payee(s) entitled to the Monies, regardless of whether another owner's name

or names may have been previously reported to the State Treasurer's Office in

addition to the name(s) of the Payee(s). Proof of payment to the Payee(s) is

attached.

The Company agrees to indemnify and hold harmless the Oklahoma State

Treasurer's Office and its employees from any claims resulting from payment of

this claim to the Company.

I declare under the penalties of perjury that I have examined this claim

(including any accompanying documents and statements) and to the best of my

knowledge and belief it is true, correct, complete, and made in good faith, for the

reimbursement of unclaimed property held by the Oklahoma State Treasurer's

Office.

Signature:______________________________

Printed name:___________________________

Title:__________________________________

State of ___________________

County of __________________

Subscribed and sworn to before the undersigned notary public this ___ day

of _____________, 20__.

My commission expires:

__________________________

______________________

Notary public

Commission no._________

[seal]

Form Affidavit For Reimbursement From Oklahoma State Treasurer'S Office, Unclaimed Property Division