I-Cash Claim Form -Illinois State Treasurer
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1D
R
AN
UTHERFORD
D
D
R
R
AN
AN
UTHERFORD
UTHERFORD
Illinois State Treasurer
DAN RUTHERFORD
Illinois State Treasurer
Illinois State Treasurer
Illinois State Treasurer
I-CASH CLAIM FORM
C
DASH C
F
I-CASH CLAIM FORM
I-CASH CLAIM FORM
ASH
LAIM
ORM
(To be used only if you have identified property on the I-Cash list. See pages 2-3 for instructions to complete this form.)
(To be used only if you have identified property on the Cash DASH list. See pages 2-3 for instructions to complete this form.)
(To be used only if you have identified property on the I-Cash list. See pages 2-3 for instructions to complete this form.)
(To be used only if you have identified property on the I-Cash list. See pages 2-3 for instructions to complete this form.)
Over $100
$10-$100
Under $10
?
Over $100
$10-$100
Under $10
?
Over $100
Over $100
$10-$100
$10-$100
Under $10
Under $10
?
?
Account Information
Account Information
Account Information
Account Information
2. Address as list
3. Social Security Number/FEIN
1. Name as it appears on list/Company Name
. 1
N
a
m
e
a
i s
a t
p p
a e
s r
o
l n
t s i
C /
o
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a p
y n
N
a
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e
. 2
A
d d
e r
s s
a
l s
t s i
d e
3. Social Security Number/FEIN
3. Social Security Number/FEIN
. 3
S
c o
l a i
S
c e
r u
y t i
N
u
m
b
r e
F /
I E
N
1. Name as it appears on list/Company Name
1. Name as it appears on list/Company Name
2. Address as list
2. Address as list
Individual Submitting Claim
Individual Submitting Claim
Individual Submitting Claim
Individual Submitting Claim
6. Midde Initial
2. First Name
4. Last Name
. 4
L
a
t s
N
a
m
e
. 5
i F
t s r
N
a
m
e
. 6
6. Midde Initial
M
6. Midde Initial
d i
l d
I e
t i n
l a i
2. First Name
2. First Name
4. Last Name
4. Last Name
9 . State
10. Zip Code
7. Current Mailing Address
8. City
9 . State
9 . State
10. Zip Code
10. Zip Code
7. Current Mailing Address
7. Current Mailing Address
8. City
8. City
7. Current Mailing Address
8. C
i
y t
. 9
S
a t
e t
1
. 0
Z
p i
C
o
e d
2 1 . Social Security Number/FEIN
11. Daytime Tele
e Number
1 1
2 1 . Social Security Number/FEIN
2 1 . Social Security Number/FEIN
1 1
11. Daytime Tele
1 1
11. Daytime Tele
e Number
e Number
1
. 1
D
y a
i t
m
e
T
l e
p e
o h
e n
N
u
m
b
r e
1
. 2
Social Security Number/FEIN
My relationship to the owner of the property
13.
:
My relationship to the owner of the property
My relationship to the owner of the property
13.
13.
:
:
My relationship to the owner of the property
13.
:
I am the owner of the property
Heir where there has been no probate
I am the owner of the property
I am the owner of the property
Heir where there has been no probate
Heir where there has been no probate
I am the owner of the property
Heir where there has been no probate
Guardian or other representative of the owner
Power of Attorney
Guardian or other representative of the owner
Guardian or other representative of the owner
Power of Attorney
Power of Attorney
Guardian or other representative of the owner
Power of Attorney
Executor or administrator for the owner
Other – explain
Executor or administrator for the owner
Executor or administrator for the owner
Other – explain
Other – explain
Executor or administrator for the owner
Other – explain_______________________________
The following should be included with this form:
The following should be included with this form:
The following should be included with this form:
The following should be included with this form:
1.
Clear copy of documentation showing the social security number of the
1.
1.
Clear copy of documentation showing the social security number of the
Clear copy of documentation showing the social security number of the
1.
Clear copy of documentation showing the social security number of the
claimant, and
claimant, and
claimant, and
claimant, and
2.
Proof of the original owner’s address as listed in box number 2 above
2.
2.
Proof of the original owner’s address as listed in box number 2 above
Proof of the original owner’s address as listed in box number 2 above
2.
Proof of the original owner’s address as listed in box number 2 above
3.
Claimant must have signature notarized (
not required if amount less than $100)
3.
3.
Claimant must have signature notarized (
Claimant must have signature notarized (
3.
Claimant must have signature notarized (
not required if amount less than $100)
not required if amount less than $100)
not required if amount less than $100)
4.
Additional documentation, as applicable, described in the instructions on pages
4.
4.
Additional documentation, as applicable, described in the instructions on pages
Additional documentation, as applicable, described in the instructions on pages
4.
Additional documentation, as applicable, described in the instructions on pages
2 and 3.
2 and 3.
2 and 3.
2 and 3.
The named claimant hereby certifies that this claim for property presumed abandoned is valid and just, that all statements herein
The named claimant hereby certifies that this claim for property presumed abandoned is valid and just, that all statements herein
The named claimant hereby certifies that this claim for property presumed abandoned is valid and just, that all statements herein
The named claimant hereby certifies that this claim for property presumed abandoned is valid and just, that all statements herein
are true and correct, and that upon payment of this claim, said claimant will indemnify and hold harmless the State of Illinois, its
are true and correct, and that upon payment of this claim, said claimant will indemnify and hold harmless the State of Illinois, its
are true and correct, and that upon payment of this claim, said claimant will indemnify and hold harmless the State of Illinois, its
are true and correct, and that upon payment of this claim, said claimant will indemnify and hold harmless the State of Illinois, its
officers and employees, from any other valid claims to the said property.
officers and employees, from any other valid claims to the said property.
officers and employees, from any other valid claims to the said property.
officers and employees, from any other valid claims to the said property.
Claimant swears and affirms that they are the proper claimant in the foregoing claim and that the above statements are true to the
Claimant swears and affirms that they are the proper claimant in the foregoing claim and that the above statements are true to the
Claimant swears and affirms that they are the proper claimant in the foregoing claim and that the above statements are true to the
Claimant swears and affirms that they are the proper claimant in the foregoing claim and that the above statements are true to the
best of their knowledge.
best of their knowledge.
best of their knowledge.
best of their knowledge.
SUBSCRIBED AND SWORN TO BEFORE ME BY
SIGNATURE OF CLAIMANT(S):
SUBSCRIBED AND SWORN TO BEFORE ME BY
SUBSCRIBED AND SWORN TO BEFORE ME BY
SIGNATURE OF CLAIMANT(S):
SIGNATURE OF CLAIMANT(S):
SUBSCRIBED AND SWORN TO BEFORE ME BY
SIGNATURE OF CLAIMANT(S):
(Claimant(s))
X
(Claimant(s))
(Claimant(s))
X
X
X_______________________________________
____________________________________ (Claimant(s))
X
X
X
X_______________________________________
THIS
DAY OF
, 20
THIS
THIS
DAY OF
DAY OF
, 20
, 20
THIS ______ DAY OF ___________________, 20_____
_______________________________________________
Mail completed form to:
Signature of Notary Public
County / State
Mail completed form to:
Mail completed form to:
Mail completed form to:
Signature of Notary Public
Signature of Notary Public
County / State
County / State
Signature of Notary Public
County / State
Illinois State Treasurer’s Office
Illinois State Treasurer’s Office
Illinois State Treasurer’s Office
Illinois State Treasurer’s Office
Unclaimed Property Division
My Commission Expires:
Unclaimed Property Division
Unclaimed Property Division
Unclaimed Property Division
P.O. Box 19495
My Commission Expires:
My Commission Expires:
My Commission Expires: __________________________
P.O. Box 19495
P.O. Box 19495
P.O. Box 19495
Springeld, IL 62794‐9495
Springeld, IL 62794‐9495
Springeld, IL 62794‐9495
Notary Seal:
Springfield, IL 62794-9495
Notary Seal:
Notary Seal:
Notary Seal:
Rev. 07/12
Rev. 07/12
Rev. 07/12
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Rev. 01/11
easurer.il.gov/programs/cash-dash/cash-dash.aspx
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