Holder Request For Reimbursement Standardized Holder Claim Form printable pdf download

INSTRUCTIONS FOR HOLDER REQUEST FOR REIMBURSEMENT

PURPOSE:

A holder of unclaimed property must complete this form for reimbursement of identical funds already paid

by Holder to rightful owner (or representative).

COMPLETION OF FORM:

All information must be complete. A separate Holder Request for Reimbursement should be submitted for

each report year and each claimant.

Part I. Holder Information:

Enter the name, address, Federal Tax ID number, telephone number, and contact person of the holder.

Part II. Claim Information:

Enter all data necessary to identify property for which the holder is seeking reimbursement. The

identification data entered on this form must be identical to the information included on the Report of

Abandoned and Unclaimed property submitted to the State by that holder.

1. Property Code-the universal NAUPA codes for the property claimed as defined on the

Summary sheet of Reported Items or Property Codes.

2. Account/Reference Number-the identification number of the property, which was entered.

3. Owner(s) name and Address-the full name(s) and address(es) of all owners(s) as shown on

the report. If “unknown” at the time of report, designate same.

4. If the account was reported in the aggregate, please indicated in the “Account/Reference

Number” column.

5. Claimant(s)-Name and Address- the full name(s) and address(es) of the person(s) who filed

the claim if different than the owner.

6. Date Paid to Claimant or Date Account Reactivated-the date the claim was paid to the

owners (or his representative) or when the holder reactivated the account.

7. Amount Paid- the amount paid for the property transmitted by the holder to the State.

8. Total of Reimbursement-the amount expected to be reimbursed to the holder by the State.

Part III. Holder Certification and Proof of Documentation:

The below MUST accompany the standardized reimbursement request form. The state will not process or

pay any requests missing this required documentation.

1. Notarized statement

2. Proof of Payment: to claimant showing identical property and dollar value. e.g. A copy of the

cancelled check(s) (front & back) or a copy of a statement or print screen showing the funds

have been re-deposited into the owner’s account.

MAIL TO:

Indiana Attorney General

Unclaimed Property Division

PO Box 2504

Greenwood IN 46142

Holder Request For Reimbursement Standardized Holder Claim Form