Security Refund Request Form - New York State Comptroller

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THOMAS P. DiNAPOLI
110 STATE STREET
STATE COMPTROLLER
ALBANY, NEW YORK, 12236
STATE OF NEW YORK
OFFICE OF THE STATE COMPTROLLER
Office of Unclaimed Funds
Security Refund Request Form
Indicate your payment preference for the security portion of your claim by initialing the line next to the option of your
choice and providing the requested information. If securities are being claimed by more than one party (joint accounts,
multiple heirs, etc.) each claimant must complete and sign a separate form.
Note: Pursuant to Section 1403 of the NYS Abandoned Property Law, the Comptroller may liquidate securities. If the
security being claimed is no longer in our inventory, we will refund the current market value, plus accruals, as required by
law. As any security transaction could have tax consequences you may want to consult with a tax advisor.
1) _______
SEND A CHECK FOR THE CASH VALUE
I would like to receive the market value for the security portion of my claim. I understand that market value is the
.
cash value of each security on the date my claim is approved for payment
WIRE TRANSFER THE SECURITY AS FOLLOWS:
2) _______
(
MUST HAVE AN ACTIVE TRADING / INVESTMENT ACCOUNT WITH A FINANCIAL INSTITUTION TO CHOOSE THIS OPTION)
Name of Broker/Agent ______________________________________________________________________
DTC Participant #
__________________________ Acct.# ________________________________________
Title of Account
___________________________________________________________________________
Broker/Agent Contact
________________________ Telephone #(___________)_______________________
ESTABLISH AN ACCOUNT WITH MUTUAL FUND COMPANY OR STOCK TRANSFER AGENT (Direct
3) _______
Registration System).
Claimant’s Name to be registered on the account __________________________________________________
Claimant’s SSN or Estate ID Number______________________ Claimant’s Date of Birth _________________
Please print your name, sign and date the form below. Each claimant must complete and sign a separate form.
______________________
__________________________________
__________________________________
Date
Claimant’s Name (Please Print)
Claimant’s Signature
Mail the completed form to: Office of Unclaimed Funds, 110 State Street, Albany, NY 12236
You can visit our website at
for answers to frequently asked questions. If you need additional
assistance, please contact our Communication Center at 1-800-221-9311 or nysouf@osc.state.ny.us.
The New York State Comptroller's Office has access to Federal, State, and local databases to verify reported information. All claims are subject to
audit. Any person knowingly submitting a fraudulent claim will be subject to ALL LEGAL PENALTIES.
NYS PERSONAL PRIVACY PROTECTION LAW NOTIFICATION: In accordance with the requirements of the NYS Personal Privacy Protection Law, you are advised that
the personal information requested on this form is being requested by the NYS Comptroller's Office of Unclaimed Funds (OUF). The OUF is authorized to collect this
information under the Comptroller's authority under Section 1406 of the NYS Abandoned Property Law to process claims to abandoned property. Please note that the
disclosure of your Social Security Number and Date of Birth on this form is completely voluntary and your claim will be processed even if your Social Security Number
and/or Date of Birth is not disclosed. However, in certain cases the Comptroller is required to report the transaction, including your Social Security Number, to the Internal
Revenue Service and other taxing authorities. If we determine that your claim is subject to such a requirement, and you do not provide your Social Security Number at this
time, we will require that you provide such information prior to payment. The personal information that is being requested, including your Social Security Number and Date
of Birth, will be used by the OUF to verify your identity and your entitlement to the property being claimed. Your failure to provide this personal information may result in
further processing time for your claim, and could, in some circumstances, result in denial of the claim where you are not otherwise able to document your identity or
entitlement to the property held by the OUF. The personal information being provided will be maintained in the Unclaimed Funds Processing System which is under the
direction of the Director of Services of the OUF, 110 State Street, Albany, NY 12236.

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