Form Up-15 - Holder Reimbursement Form
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1UP-15 (Rev. 06/2013)
GEORGIA DEPARTMENT OF REVENUE
UNCLAIMED PROPERTY PROGRAM
GEORGIA DEPARTMENT OF REVENUE
UNCLAIMED PROPERTY PROGRAM
4125 WELCOME ALL RD SUITE 701
ATLANTA, GEORGIA 30349
HOLDER REIMBURSEMENT
FORM
ABANDONED ACCOUNT INFORMATION
1. ACCOUNT NAME
2. SECONDARY ACCOUNT NAME (if applicable)
3. REPORTED ADDRESS
4. ACCOUNT NUMBER
5. PROPERTY CODE
6. ACCOUNT BALANCE REMITTED
WHO IS REQUESTING REIMBURSEMENT
7. TAX ID#
8. HOLDER NAME
9. ADDRESS
10. REPORT YEAR
11. CONTACT PERSON
CONTACT PHONE NO.
12. PAGE NUMBER
(
)
AGGREGATE VERIFICATION (complete only if account is less than $50.00)
It is hereby verified that for report year 13a. 20_______,
13b. $____________________ was remitted in an aggregate amount. Of this amount,
13c. $___________________ was remitted in the name(s) of 13d. ___________________________________________________________________ .
Acceptable proof has been submitted to this holder to prove rightful ownership.
AFFIDAVIT AND INDEMNITY AGREEMENT
It is hereby certified that this claim is valid, just and due. Claim has not been previously paid to the holder. Request is hereby made to the Georgia
Revenue Commissioner to return to the holder the above stated account that previously paid to owner. Upon return of this property to the holder, the
Georgia Department of Revenue, Unclaimed Property Officers and Employees are indeminified and held harmless for any damages, claims or losses of
any kind resulting from payment of this claim. The holder agrees to return the property to the Georgia Department of Revenue, Unclaimed Property
Program if it is later determined that rightful ownership has been established by another party.
SIGNATURE OF AUTHORIZED OFFICIAL
SIGNATURE OF HOLDER REPRESENTATIVE
TITLE OF AUTHORIZED OFFICIAL
TYPED NAME OF HOLDER REPRESENTATIVE
Sworn to and subscribed before me, this _______ day of ________________________________
TYPED NAME OF NOTARY PUBLIC
SIGNATURE OF NOTARY PUBLIC
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