WARNING:
To protect against the possibility of others accessing your confidential
information, do not complete these forms on a public workstation.
Washington State
Department of Revenue
Unclaimed Property Section
PO Box 47477
CERTIFICATE OF HOLDER
Olympia, WA 98504-7477
(360) 570-3264
Reset This Form
1. Holder Number or FEIN
2. Holder (Required)
3. Verified Legal Claimant Information
Holder Name
Claimant Name (if different)
C/O or Attention
C/O or Attention
Mailing Address
Mailing Address
City, State, Zip
City, State, Zip
(
)
Phone Number
4. Claim Information
Reported Owner’s Name
ID Number
Yes
No
Amount Received
Year Reported
Property Type
Aggregate
5. Payment Options (Required)
Holder Repaid Owner (See instructions on back)
Reported in Error (See instructions on back)
Make Check Payable to the Holder for the Benefit of
Reimburse the Claimant
the Claimant(s). (Documentation required)
6. Holder 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
Please See Reverse Side for Detailed Instructions
REV 80 0007 (7/10/13)
Print This Form