Form Rev 80 0007 - Certificate Of Holder - Washington State Department Of Revenue
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1WARNING:
To protect against the possibility of others accessing your confidential
information, do not complete these forms on a public workstation.
Washington State
Department of Revenue
Unclaimed Property Section
PO Box 34053
Seattle, WA 98124-1053
(360) 705-6706
CERTIFICATE OF HOLDER
Reset This Form
Department Use Only
1. Unclaimed Property Account No.:
2. Verified Legal Claimant Information:
3. Holder Information:
Reported Owner Name
Holder Name & Holder Number
Claimant Name (if different)
Attention
Attention
Mailing Address
Mailing Address
City, State, Zip
(
)
City, State, Zip
Phone Number
4. Claim Information:
$ ______________
______________
____________
____________
Yes
No
Amount Reported
Year Reported/
ID Number
Property Type
Aggregate
Sequence Number
5. Holder Declaration and Notary:
I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true
and correct.
________________________________________
City and state in which signed
_________________________________________________________________________________________________
Signature and Title
Date
Subscribed and sworn to before me this ________ day of _______________________ , 20 ________________
______________________________________________
_________________________________________________
Notary Public (print name)
Notary Public (signature)
______________________________________________
_________________________________________________
Residing at
Commission Expires
Print This Form
Please See Reverse Side for Detailed Instructions
REV 80 0007 (7/5/12)
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Parent category: Financial