Certificate Of Holder Page 2
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2CERTIFICATE 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
1. Unclaimed Property Account No.: To be completed by the Unclaimed Property office.
2. Verified Legal Claimant Information: Provide the reported owner’s name, the claimants’ name (if
different from the owner’s name), any “attention to” or “in care of”, and the mailing address for the
claimant (address to which refund should be mailed).
3. Holder Information: Provide the holder’s name and holder number (if known), the mailing address, and
the holder’s phone number.
4. Claim Information: Please provide us with the dollar amount reported for this owner, the year reported
(and sequence number if more than one report was sent for that year), the identification number, property
type, and whether it was reported as an aggregate.
5. Holder’s Declaration and Notary: Please sign, date and have your signature notarized.
Holder Repaid Owner:
Complete the Certificate of Holder as indicated above, except in section 2, enter the reported owner’s name
and for claimant write “Same as Holder”. Include proof of repayment (positive owner contact) which may be
a photo copy of the front and back of a canceled check, or a statement signed by the claimant acknowledging
repayment.
Reported in Error:
Complete the Certificate of Holder as indicated above, except in section 2, enter the owner’s name then for
claimant write “Same as Holder”. Include a detailed explanation and any documentation justifying why this
was an error.
For assistance visit ucp.dor.wa.gov or call 1-800-435-2429. To inquire about the availability of this document in an alternate format
for the visually impaired, please call (360) 705-6715. Teletype (TTY) users please call (360) 705-6718.
Rev 80 0007 (7/5/12)
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