Holder Refund Request Form printable pdf download

NC DEPARTMENT OF STATE TREASURER

HOLDER REFUND REQUEST

1. ORIGINAL HOLDER:

Name

Holder ID

Address

FIN

City

State

Zip

Contact Person

Telephone (

)

2. PROPERTY IDENTIFICATION:

Amount Due Rightful Owner(s)

Owner Name(s)

Total $ Amount of Report

Date Reported

Owner Address

Receipt Number or Report ID Number, if known

If property was reported in Aggregate, please provide Aggregate Amount

3. PAYMENT OPTIONS:

(Check one)

_____ Refund Holder for funds submitted to Escheat Fund in error. (Written explanation required.)

_____ Reimburse Holder for moneys paid to Claimant(s). (Provide copy of front and back of cancelled check.)

_____ Make check payable to the Holder for the benefit of Claimant(s). (Documentary evidence required.)

4. REQUIRED HOLDER DOCUMENTARY EVIDENCE:

List and provide the documentary evidence from Holder’s records that supports refund request. Required

documents may include cancelled check, print screen showing funds reinstated, accounting records, etc. :

If such evidence is not available, provide a letter of explanation to support refund request.

5. CERTIFICATIONS:

This form must be signed and notarized by two principal officers of the Holder OR one principal officer and an

authorized employee of the Holder.

We agree to the indemnification provisions of G.S. 116B-67(b) and (e), and we hereby certify that we are principal

officer(s) and/or an authorized employee of the original Holder or a legal successor thereto, and we further certify

that this claim has been reviewed and the information provided is true and correct. By demonstrating that the

owner was paid or reinstated, or funds were sent in error, we hereby certify this Claim is valid and just.

Print Name and Title:

Sworn this ________day of _____________

Signature:

Notary Public: _______________________

Print Name and Title:

State of _____________________________

Signature:

My commission expires: ________________

(Seal)

Please mail completed form and documentary evidence to:

NC DEPARTMENT OF STATE TREASURER

UNCLAIMED PROPERTY PROGRAM

PO BOX 20431

RALEIGH, NORTH CAROLINA 27619-0431

If you have any questions, please call 919-508-1000 and we will be glad to assist you.

(Rev 8/10)

Holder Refund Request Form

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