Holder Request For Reimbursement Standardized Holder Claim Form


A holder of unclaimed property must complete this form for reimbursement of identical funds already paid
by Holder to rightful owner (or representative).
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.
Indiana Attorney General
Unclaimed Property Division
PO Box 2504
Greenwood IN 46142


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