Claim Information Affidavit - New York State Comptroller - 2012
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1
2Rev 11/29/12
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
Claim Information Affidavit
Date:__________________
Reference Number: __________________
Part A. This affidavit must be completed by the Reporting Organization and notarized. The information below
must come from the final report verification and checklist submitted to this office.
(1)
(2)
On
_______________, 20__________, we
___________________________________________ remitted
(3)
abandoned property reported in the amount of
$______________________, receipt #________________________ to
(4)
the Office of Unclaimed Funds, for the period ending
_________________. In this report, on tape sequence or
(5)
diskette counter number
_______________(OR) page___________ and line__________ was the following property:
(Please complete the appropriate section – See page 2 for additional details)
CASH AMOUNTS REPORTED
(6)
(7)
(8)
cash amount
$ _____________,representing property type
________ , reported in the name of
_____________________ .
(9)
(10)
____________________________________is entitled to the amount of
$________________________________________
BOND AMOUNTS REPORTED
(11)
(12)
(13)
the amount
$ ______________, representing property type
__________ , for bond issue
_________________________,
(14)
(15)
bond/coupon number(s)
_________________________,with a face value of
$_______________________ per bond/coupon.
(
16)
(17)
This bond(s) had an early redemption with a due date of
_______________ and a value of
$__________________ per bond.
(18)
(19)
The bond was reported in the name of
________________________________.
______________________is entitled to the
(20)
amount of
$_______________________.
Preparer's Name:__________________________________________________________________________________
(Please Print Name)
Preparer’s Signature:_______________________________________________________________________________
Employer Tax Identification Number:___________________ Daytime Telephone Number: (_____)__________________
Sworn to me this ____________ day of ___________ 20 _______
______________________________________________________
NOTARY SIGNATURE
Please be sure to complete and return both pages of the form.
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