Unclaimed Nclaimed Property - Reporting Booklet - Washington Department Of Revenue Page 18
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28Certificate of Holder
Certificate of Holder
The Certificate of Holder is used in the
following situations:
Incomplete information:
The claimant and the Unclaimed Property
office do not have enough information to
verify a claim.
Holder repaid owner:
If you, the holder, choose to repay the owner
directly rather than sending the owner to our
office, you would complete this form.
Holder reported in error:
A report has been filed and you realize a
certain item or items should not have been
reported.
INSTRUCTIONS
INSTRUCTIONS
INSTRUCTIONS
INSTRUCTIONS
INSTRUCTIONS
1. Unclaimed Property Account No.:
To be
5. Holder’s Declaration and Notary:
completed by the Unclaimed Property office.
Please sign, date and have your signature
notarized.
2. Verified Legal Claimant Information:
Provide the reported owner’s name, the
Holder repaid owner:
claimant name (if different from the owner’s
Complete the Certificate of Holder as indi-
name), any “attention to” or “in care of”, and
cated above, except in section 2, enter the
the mailing address for the claimant (address
reported owner’s name and for claimant write
to which refund should be mailed).
“Same as Holder”. Include proof of repay-
ment (positive owner contact) which may be
3. Holder Information:
Provide the holder’s
a photocopy of the front and back of a
name and holder number (if known), the
canceled check, or a statement signed by the
mailing address, and the holder’s phone
claimant acknowledging repayment.
number.
Reported in error:
4. Claim Information:
Please provide us with
Complete the Certificate of Holder as indi-
the dollar amount reported for this
cated above, except in section 2, enter the
owner, the year reported (and sequence
owner’s name then for claimant write “Same
number if more than one report was sent for
as Holder”. Include a detailed explanation and
that year), the identification number, property
any documentation justifying why this was an
type, and whether it was reported as an
error.
aggregate.
Unclaimed Property Reporting Booklet
19
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