Claim Form - Office Of The State Treasurer John D. Perdue, State Treasurer

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Office of the State Treasurer
For Office Use Only: RFA: ________________________
John D. Perdue, State Treasurer
PR: ________________________
Unclaimed Property Division
CM/DUP: ____________/___________
800-642-8687 or 304-558-2937
FIMS: ________________________
CLAIM FORM
Claimant’s Individual - First and Last Name OR Business
Federal Privacy Notice Act:
Providing your Social
Security number (SSN) is optional, however, if you choose not to
1
provide your SSN, there may be insufficient information available
Claimant’s Mailing Address
to determine whether you are the owner of the unclaimed property
2a
held by the Division.
Exception: SSNs must be provided on a W-9 form by recipients of
Claimant’s Street Address
2b
interest-bearing or security-related instrument property. The
Division is required to report names and SSNs of recipients of
certain types of payments to the Internal Revenue Service (IRS). If
your payment includes interest paid to you, you will receive an IRS
City
State
Zip
3
1099INT form. If you received cash as the result of security related
transaction, you will receive an IRS 1099B form. If your payment
included any accrued cash dividends on securities, you will receive
an IRS 1099MISC form. All IRS information tax reports are mailed
Claimant’s Phone Number and email address - if applicable
4
during January following the end of the current calendar year. If
you have any questions regarding your tax liability, please consult
with an appropriate tax specialist.
(
)
Claimant’s Social Security # OR Business FEIN
5
If you provide your SSN, the Division will only disclose it to
employees involved in paying your claim, to the federal
government as required by law and in administering the Unclaimed
Are you the owner of the property? Yes or  No
Property Act.
(Check One)
6
- If “no”, Print Owner’s Name:
Is owner deceased? Yes or  No
(Check One)
7
Mail completed form to:
- If “yes”, Is estate Open  or Closed ?
(Check One)
Office of State Treasurer
- If “Open”, print Administrator’s Name:
Unclaimed Property Division
One Players Club Drive
Charleston, WV 25311
The following must be included with this form:
- Copy of Driver’s License or other legal photo identification and
- Copy of Social Security Number (See above the Federal Privacy Notice Act) or FEIN (See Instructions, Box 5)
If you have questions filing this claim, please follow the instructions on the next page.
Under penalty of perjury, each of the undersigned claimants agrees to the following: that all the information on this form and the
attachments is true and complete; that, to the best of his/her knowledge, he/she has a legal or equitable interest in abandoned
property being held by the State of West Virginia Treasurer; that he/she will only accept payment of property to which he/she is
entitled under the West Virginia Unclaimed Property Act; that will immediately return any property to which he/she becomes
aware that he/she is not entitled; and will indemnify and hold harmless the Unclaimed Property Division, the State Treasurer’s
Office, their officers and employees, and the State of West Virginia against claims to the property by another claimant.
Claimant Signature(s): (all claimants must sign and have notarized)
Notary Stamp
___________________________________________ Date ______________
___________________________________________ Date ______________
Subscribed and sworn to before me this ____ day of __________________
State______ County _____________ My Commission Expires __________
Notary Public Signature ___________________________________
Revised 12/2008

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