Unclaimed Property Holder Claim Form With Filing Instruction (Page 2 of 2) in pdf

Unclaimed Property Holder Claim Form With Filing Instruction Page 2

Unclaimed Property Holder Claim Form

Filing Instruction

THE HOLDER CLAIM FORM MUST BE FULLY COMPLETED BEFORE ANY CLAIM MAY BE

PAID.

Section A: Provide the name of a contact person, including email and telephone number. Fill in the name,

address and Federal Tax I.D. number of your organization as it appeared on the most recent report.

Section B: Provide the details for the report that this refund request relates to. Enter the dollar amount of the

refund requested.

Section C: Choose the type of refund you are requesting.

1. Use Box 1 if your request relates to the entire report and is not specifically for an account on the report.

Attach documentation to support your refund request.

2. Use Box 2 if your request for a refund is for a specific account on your report. If you are requesting a refund

for multiple accounts, you may provide an Excel spreadsheet listing for the detail on each account, with a

summary total in Section B for the Total Amount of refund requested.

Provide information about the REPORTED OWNER and SECOND OWNER (where applicable). Fill in the

name(s) and address as originally reported. Please note: refund requests cannot be made for accounts

reported in the Aggregate, unless you have previously provided detail owner information for each account

that makes up the Aggregate total.

Please check the box for the type of refund and attach corresponding documentation. If the account was

reported in error, or the payee is no longer due the funds, a brief written explanation is needed. If the owner

has already been paid, just document this by attaching the back and front copy of the cancelled check or

proof of the reactivation of the owner account.

Section D: Sign the Affidavit according to the instructions.

Section E: Please return this completed form with original signatures to the mailing address (keep a copy for

your records). Copies or faxed forms are not acceptable.

Unclaimed Property Holder Claim Form With Filing Instruction Page 2