Reporting Organization Reimbursement Form

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THOMAS P. DiNAPOLI
110 STATE STREET
STATE COMPTROLLER
ALBANY, NEW YORK, 12236
STATE OF NEW YORK
OFFICE OF THE STATE COMPTROLLER
OFFICE OF UNCLAIMED FUNDS
Reporting Organization Reimbursement Form
Name of Reporting Organization
Contact Name
TAXPAYER
IDENTIFICATION
NUMBER(SSN/FEIN)
Address
City
State
Zip
Telephone
Email Address
Owner Name
Address of Record
Amount
Year
Reported
(Please identify if it’s an unknown
(if an unknown owner, please identify dormancy date)
(if in an aggregate,
owner)
please specify
aggregate total and
amount due owner)
1
2
3
4
Total Amount of Report
Property ID Number
Property Type
5
6
7
Payee name and current address
TAXPAYER IDENTIFICATION
NUMBER(SSN/FEIN)
8
9
10. If the property was reported in error, please explain in the area provided below and submit proof of same.
11. If owner has already been paid, please see instructions on next page.
12. “In consideration of the payment of this claim, I/we will reimburse to the Office of the State Comptroller and
theState of New York the amount due to any additional persons who are entitled to these funds. Under penalty of
perjury, I certify that the information on this affidavit is true and correct.”
SIGNATURE OF OFFICER
DATE
Please complete this form and mail it to:
Sworn to me this ____________ day of ___________ 20 _______
Office of Unclaimed Funds
110 State Street
______________________________________________________
Albany, NY 12236
NOTARY SIGNATURE
For assistance contact us by telephone at 800-221-9311 or at We can also be reached by
email at nysouf@osc.state.ny.us.

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