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Holder Reimbursement Request Form - Unclaimed Property - North Carolina Department Of State Treasurer

Holder Reimbursement Request

This form should only be used to

request a reimbursement for funds returned to the owner.

1. HOLDER INFORMATION

Name:

Holder ID:

Address:

FIN:

City:

State:

Zip:

Contact:

Phone: (_ )

Email:

2. REPORT INFORMATION

Total Amount of Report: $

Date Reported:

Reported

Owner

Name(s):

Reported Owner

Address:

Reported Owner

Amount:

If property was reported in Aggregate, provide Aggregate amount: $

3. CLAIMANT/OWNER INFORMATION

Date Claimant Paid/Account Reactivated:

Amount

Paid

Claimant:

Claimant Current

Name(s):

Claimant Current Address:

4. REQUIRED HOLDER DOCUMENTARY EVIDENCE

List below and provide documentary evidence from Holder’s records that reflects the payment or account

reactivation of property to the claimant, and that the claimant was entitled to the payment.

In the case in which the holder has made a payment on a negotiable instrument, including a traveler’s check or money

order, holder must provide proof that the instrument was duly presented and that payment was made to a person who

reasonably appeared to be entitled to payment.

Required documents may include a cancelled check , a print screen showing funds reinstated, etc. If such evidence is not

available, provide a letter of explanation to support reimbursement request.

P.O. Box 20431 • Raleigh, North Carolina 27619-0431

Telephone: (800) 582-0615 • Fax: (919) 855-5811 •

Holder Reimbursement Request Form - Unclaimed Property - North Carolina Department Of State Treasurer