Certificate Of Holder - Washington State Department Of Revenue Page 2
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1
2INSTRUCTIONS
1. Holder Number or FEIN: Provide holder number. If unknown provide FEIN.
2. Holder Information: Provide the holder’s name, C/O or attention, the mailing address, and the holder’s
phone number.
3. Verified Legal Claimant Information: Provide the claimants’ name (if different from the owner’s
name), any “attention to” or “in care of”, and the mailing address for the claimant (address to which
refund should be mailed).
4. Claim Information: Please provide us with the dollar amount reported for this owner, the year reported
(and sequence number if more than one report was sent for that year), the identification number, property
type, and whether it was reported as an aggregate.
5. Payment Options:
Reimburse the Claimant:
Complete the Certificate of Holder as indicated above, include any documentation.
Holder Repaid Owner:
Complete the Certificate of Holder as indicated above, except in section 3, enter the reported owner’s
name and for claimant write “Same as Holder”. Include proof of repayment (positive owner contract)
which may be a photo copy of the front and back of a canceled check, or a statement signed by the
claimant acknowledging repayment.
6. Holder’s Declaration and Notary: Please sign, date and have your signature notarized.
For assistance visit ucp.dor.wa.gov or call 1-800-435-2429. To inquire about the availability of this document in an alternate format,
please call 1-800-647-7706. Teletype (TTY) users please may use the Washington Relay Service by calling 711.
Rev 80 0007 (1/30/17)
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