Claim Information Affidavit - New York State Comptroller - 2012 Page 2

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Rev 11/29/12

New York State Comptroller’s Office – Office of Unclaimed Funds

Claim Information Affidavit

Page 2

Part B. Must be completed by the person entitled to these funds and notarized.

In consideration of the payment, I/we will save the State Comptroller and the State of New York from any loss due to such

payment. Under penalty of perjury, I certify that the information on this affidavit is true and correct and that the number

shown on this affidavit is the correct Taxpayer Identification Number.

Claimant's Name:__________________________________________________________________________________

(Please Print Name)

Claimant’s Signature:_______________________________________________________________________________

Tax Identification Number:________________________ Daytime Telephone Number: (______)____________________

Address _________________________________________________________________________________________

Email Address (Optional)_____________________________

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.

NYS PERSONAL PRIVACY PROTECTION LAW NOTIFICATION: In accordance with the requirements of the NYS Personal Privacy Protection Law, you are advised that the

personal information requested on this form is being requested by the NYS Comptroller's Office of Unclaimed Funds (OUF). The OUF is authorized to collect this information

under the Comptroller's authority under Section 1406 of the NYS Abandoned Property Law to process claims to abandoned property. Please note that the disclosure of your

Social Security Number and Date of Birth on this form is completely voluntary and your claim will be processed even if your Social Security Number and/or Date of Birth is not

disclosed. However, in certain cases the Comptroller is required to report the transaction, including your Social Security Number, to the Internal Revenue Service and other

taxing authorities. If we determine that your claim is subject to such a requirement, and you do not provide your Social Security Number at this time, we will require that you

provide such information prior to payment. The personal information that is being requested, including your Social Security Number and Date of Birth, will be used by the OUF

to verify your identity and your entitlement to the property being claimed. Your failure to provide this personal information may result in further processing time for your claim,

and could, in some circumstances, result in denial of the claim where you are not otherwise able to document your identity or entitlement to the property held by the OUF. The

personal information being provided will be maintained in the Unclaimed Funds Processing System which is under the direction of the Director of Services of the OUF, 110

State Street, Albany, NY 12236.

(See page 3 for instructions)