Unclaimed Property Claim Form - Mississippi Treasury Department printable pdf download

State of Mississippi Treasury Department

P O Box 138 Jackson, MS 39205

Telephone 601-359-3534

LYNN FITCH

Tony Geiger, Director

Unclaimed Property

State Treasurer

Unclaimed Property Division

Claim Form

PROPERTY ID # ___________________

Instructions: Read documentation checklist carefully to complete this form

Please provide all required information; without it we cannot process your claim request.

You must send a copy of your drivers license & social security card with this claim!

A. Claimant’s Name and Current Address:

B. Original owner name as listed on

Website or Letter:

__________________________________________

_________________________________________

__________________________________________

_________________________________________

__________________________________________

_________________________________________

Social Security Number/Tax I.D. ________________________________

Daytime phone number ________________________________________

C. If your name is different from the name shown in Section B, please explain why:

_____ Marriage/Divorce ………..Attach a copy of filed papers

_____ Owner is deceased……..Your relationship to deceased _____________________________________

_____ Guardian, executor, administrator

_____ Other……Please explain: ____________________________________________________________

_____________________________________________________________________________

Subscribed and sworn to before me this

Affidavit: The named claimant hereby certifies that this claim for property presumed

_______Day of _________________, 20____

abandoned is valid and just, that all statements herein are true and correct, and that

upon payment of this claim said claimant will indemnify and hold harmless the State,

______________________________________________

its officers and employees, from any other valid claims to the said property.

Notary Public

County/State

Signature(s) of ALL Claimants – Must be Notarized

My commission expires__________________

__________________________________________________________________

______Day of ___________________, 20___

_______________________________________________

__________________________________________________________________

Notary Public

County/State

Due to heavy demands on our small staff,

please allow from 4 to 6 weeks for a response.

My commission expires__________________

Unclaimed Property Claim Form - Mississippi Treasury Department

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