Unclaimed Property Estate Claim Declaration Form
Download a blank fillable Unclaimed Property Estate Claim Declaration Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Unclaimed Property Estate Claim Declaration Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3E-Claim
West Virginia State Treasurer’s Office – Unclaimed Property
Unclaimed Property Estate Claim Declaration
State of _____________________
County of _____________________
I, ___________________________________________, first being duly sworn, under penalty of perjury, hereby state
as follows:
1. That I am claiming property in the name of __________________________ (the “Reported Owner”).
2. That __________________________ (Reported Owner's name), died on _______________ (date of death), in
_______________________________ (place of death), as shown on a copy of the Reported Owner’s death certificate
attached to this declaration.
.
3
That no person is currently qualified as administrator over the reported owner’s estate.
4. That: (circle one)
a. the Reported Owner left no will, OR
b. that a copy of the Reported Owner’s final will is attached.
5. That I have exercised due diligence to determine whether there are any outstanding debts of the Reported Owner’s
estate, and to the best of my knowledge there are none.
6. That my relationship to the Reported Owner is that of __________________, and that the attached Table of Heirship
is true and correct to the best of my knowledge and belief.
7. That no other person has a superior right to the property I am claiming.
8. That: (circle one)
a. each of the Reported Owner’s remaining heirs has signed a limited power of attorney, authorizing me to
collect the property on his of her behalf, and attached to this document, OR
b. that I am claiming only my share of the Reported Owner’s property.
9. That all the information on this form and the attachments is true and complete; that I will only accept payment of
property to which I am entitled under the West Virginia Unclaimed Property Act; that if claiming the property for
others as indicated above, I will distribute the property to the heirs entitled to it; that I will immediately return any
property to which I become aware that I am not entitled; and that I will indemnify and hold harmless the Unclaimed
Property Division, the State Treasurer’s Office, their officers and employees, and the State of West Virginia against
any loss resulting from payment of this property to me.
Claimant Signature: ___________________________________________ Date ________________
Notary Stamp
Subscribed and sworn before me this _____________(date)
by _______________________________________
My commission expires _____________________
_________________________________________
Notary Public
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial