Holder Request For Reimbursement Form - Kentucky Department Of Treasury printable pdf download

Holder Request For Reimbursement Form - Kentucky Department Of Treasury

HOLDER REQUEST FOR REIMBURSEMENT

Kentucky Department of Treasury

PLEASE TYPE OR PRINT

PART I. HOLDER INFORMATION

Holder Name: _____________________________________ FEIN: ___________ Contact: ___________________________________________ Tel: ___________________

Address: ______________________________________________________ City: ________________________________ State: _________Zip Code: ___________________

PART II. CLAIM INFORMATION

Owner(s) Name

Acct/Reference #

Owner(s) Address

Date Paid to Claimant

Year

Amount Paid

Amount of entire deposit

(Exactly as reported)

or Acct Reactivated

Reported

(If aggregate, specify)

in which this was contained

If amount was remitted in error, please attach a written explanation.

TOTAL AMOUNT OF REIMBURSEMENT

One of these must be attached to this claim: Copy of replacement check to owner (front and back)

PART III. HOLDER CERTIFICATION

Account reactivation document

ORIGINAL travelers checks/money orders

State of _______________ County of _____________ s s

I, ______________________________ , a duly authorized representative of the holder listed above, do hereby certify that the above listed funds, which were listed in the

Report of Unclaimed Property filed by the holder, have been paid to the rightful owners or their representatives. I agree, upon payment of the above described property, to

indemnify the state and hold it harmless from all claims and loss, demands, costs and other expenses which the state may sustain by reason of turning over the property to

the holder and by reason further of its refusal to pay the property to any other person or persons.

Signature of Representative ____________________________________ Date ____________

Subscribed and sworn to before me this ____ day of _________ , 20 ____

Name of Representative (Type or Print) ___________________________ Date ____________

Notary Signature (and Seal) _______________________________________

Please mail to: KENTUCKY DEPARTMENT OF TREASURY, UNCLAIMED PROPERTY DIVISION, 1050 US HWY. 127 S., SUITE 100, FRANKFORT KY 40601

Holder Request For Reimbursement Form - Kentucky Department Of Treasury

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