Unclaimed Nclaimed Property - Reporting Booklet - Washington Department Of Revenue Page 19

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State of Washington
Department of Revenue
Special Programs Division
Unclaimed Property Section
PO Box 448
Olympia, WA 98507-0448
CERTIFICATE OF HOLDER
1. Unclaimed Property Account No.:
2. Verified Legal Claimant Information:
3. Holder
Reported Owner s Name
Holder s Name & Holder Number
Claimant s Name
c/o or Attention
c/o or Attention
Mailing Address
Mailing Address
City, State, Zip
(
)
City, State, Zip
Phone Number
4. Claim Information:
$
Yes
No
Amount Reported
Year Reported/
ID Number
Property Type
Aggregate
Sequence Number
5. Holder s Declaration and Notary:
I certify under penalty of perjury under the laws of
the State of Washington that the foregoing is true
and correct.
Date and Place
Signature and Title
Subscribed and sworn to before me this
day of
, 20
Notary Public (print name)
Notary Public (signature)
Residing at
Commission Expires
REV 80 0007-1 (8-28-01)
Please See Reverse Side For Detailed Instructions
Unclaimed Property Reporting Booklet

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