Affidavit And Agreement Supporting Claim For A Business Or Organization Form
ADVERTISEMENT
1Affidavit and Agreement Supporting
Claim for a Business or Organization
I, the undersigned Claiming Agent, as authorized representative or former owner of the below-identified
business or organization claiming certain unclaimed property now held in custody by the Office of the State
Treasurer, said property being specifically referenced below by property identification number(s), after being duly
sworn, do hereby affirm as follows:
B
/O
(L
O
) I
:
USINESS
RGANIZATION
ISTED
WNER
NFORMATION
N
B
/O
C
: __________________________________________
AME OF
USINESS
RGANIZATION FILING
LAIM
C
N
SSN (
): _____________________________________________
LAIMANT
AME AND
IF FORMER OWNER
M
: _____________________________________________________________
A
(
)
AILING
DDRESS
CURRENT
______________________________________________________________________________________
B
TIN: _____________________________ T
: _________________________________
USINESS
ELEPHONE
P
C
:
ROPERTY
LAIMED
The above-named business/organization/former owner is the rightful owner of property that the Office of
the State Treasurer associates with the following property identification number(s):
__________________________.
C
’
T
C
A
:
LAIMING AGENT
S CAPACITY
O
LAIM AND ENTER
GREEMENT
I am solely authorized to place this claim and bind the Claimant in the below-stated A
because:
GREEMENT
I own or am an officer of the entity listed as the unclaimed property owner;
I own or am an officer of the entity that acquired the business listed as the unclaimed property owner and
enclose proof of said acquisition;
I am the former owner of the business listed as the unclaimed property owner, but disposed of the
business on or about ________________________ (date) by selling it. I enclose a copy of the signed
Purchase and Sale Agreement showing I retained the assets at the time of sale;
I am the former owner of the business listed as the unclaimed property owner, but I disposed of the business
on or about ________________________ (date) by closing it.
A
: Claimant agrees to indemnify and hold harmless the Office of the State Treasurer against any
GREEMENT
superior claim(s) made on the above-claimed property.
Claiming Agent’s Signature: _________________________________________________
Date: ____________
Claiming Agent’s Name (printed): ________________________________________________________________
Personally appeared before me the said Claiming Agent and affirmed the above-stated facts as true and correct
based upon his/her own personal knowledge.
County _____________________________ State __________________
Subscribed and sworn before me on: _____________________________
(seal)
Notary Public: _______________________________________________
My commission expires: ________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial