Request For Holder Reimbursement - State Of Nevada Office Of The State Treasurer
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1State of Nevada Office of the State Treasurer
Unclaimed Property
555 East Washington Avenue, Suite 4200, Las Vegas, NV 89101-1075
REQUEST FOR HOLDER REIMBURSEMENT
HOLDER INFORMATION
Tax/FEIN Number:
Holder Information:
Mailing Address:
City:
State:
Zip Code:
Contact Person:
Phone Number:
Fax Number:
PROPERTY INFORMATION
Report Year:
Report Amount:
Property Type:
Date Paid to Owner:
Amount Paid to Owner:
Number of Shares:
Name as indicated on Report (owner):
Is this Aggregate?
Yes
No
Owner Address:
NOTE: A copy of the proof of payment made to rightful owner must be accompanied with this request.
HOLDER INDEMNIFICATION AND AFFIDAVIT
I, __________________________________, a duly authorized representative of the holder listed above, do hereby certify that the
above listed funds, or other property that was listed in the report filed by the holder have been paid to the rightful owner(s) or their
appointed representative. I agree, upon payment of the above described property, to indemnify the state of Nevada and hold it
harmless from all claims and losses, demands, costs, and other expenses which the State may sustain by reason of turning over
property to the holder and by reason further of its refusal to pay the property to any other person or persons:
Name of Representative (type or print legibly) __________________________________ Title ____________________________
Signature of Holder Representative __________________________________________ Date____________________________
NOTARY
Sworn to and subscribed before me this
(Notary Stamp)
_______ day of _________________, 20______
Notary: ________________________________
My Commission expires: __________________
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