Form Up-4 - Holder Request For Reimbursement

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HOLDER REQUEST FOR REIMBURSEMENT
State of _____________________ Report Year ______________
PART I HOLDER INFORMATION
Holder Name
Address
City
State
Zip
Tax ID#
Contact
Contact Telephone No.
PART II CLAIM INFORMATION
S
Property Code
Acct. Reference No. (If Aggregate – Specify)
Date Pd. To Owner/Acct. Reactivated *
Amount Paid
Owner’s Name (Exactly as on Report)
Owner’s Address (As Listed on Report)
Claimant’s Name & Address (If Different than Owner)
*IF AMOUNT WAS REMITTED IN ERROR, ATTACH A
SEPARATE SHEET DETAILING THE ERROR
Total Request for Reimbursement:
$ _________
PART III HOLDER CERTIFICATION
Sworn to and subscribed before me
this
I, _________________________________ a duly authorized representative of the holder listed above, do hereby certify
that the above listed funds, or other property which was listed in the Report filed by the holder, have been paid to the
__________day of ___________, 20 _____
rightful owner(s) or their appointed representative. 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
Notary:_____________________________
by reason returning property to the holder and by reason further of its refusal to pay the property to any
other person or persons:
My commission expires:_______________
Name and Title of Holder Representative (type or print)________________________________________
UP-4 (04/17/13) Page 1 of 2
Signature of Holder Representative ______________________________________ Date______________
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