Holder Request For Reimbursement - Connecticut State Treasurer
ADVERTISEMENT
1H
R
F
R
OLDER
EQUEST
OR
EIMBURSEMENT
S
C
TATE OF
ONNECTICUT
O
S
T
FFICE OF THE
TATE
REASURER
U
P
D
FOR FUNDS PAID TO THE STATE ON
NCLAIMED
ROPERTY
IVISION
TH
55 E
S
, 5
FLOOR
DATE/AMOUNT OF HOLDER REPORT:
LM
TREET
H
, CT 06106
ARTFORD
MONTH: ________DATE: _______YEAR: _______AMOUNT:_____________
Part I. Holder Information
Name of Holder
Tax ID
Street
City
State
Zip Code
Telephone Number
Part II. Claim Information
(Please attach supporting documentation for this request/use separate sheet for additional properties)
Property
Account/Reference
Claimant(s) Name
Owner(s) Name (Exactly
Claimant(s) Address (If different
Date Account
Owner’s Address
Code-NAUPA
Number (If an
(If different than
Amount Paid
as provided on report)
than owner(s)
Reactivated
Code
aggregate, specify)
owner)
If amount was remitted in error, please attach a written explanation.
Total Amount of reimbursement
Part III. Holder Certification
I, _________________________________________________, a duly authorized representative of the holder listed above, do hereby certify that
the above listed funds, which were reported and remitted on a Report of Unclaimed Property filed by the holder have been paid to the rightful
owner(s) or their representatives or were remitted in error to the State of CT. 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 ___________________________Date ________Subscribed and sworn to before me this _______ day of _________, 20_____
Print Name of Signatory: ________________________Notary Signature, Date and Seal: ________________________________________
Revised: December 2012
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal