Claim Form - New York State Comptroller

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Thomas P. Di Napoli
110 State Street
Comptroller
Albany, NY 12236
Office of the New York State Comptroller
Office of Unclaimed Funds
Claim Form
1
CLAIMANT INFORMATION:
Please enter your name and current address.
LAST NAME
FIRST NAME
M.I
.
STREET ADDRESS
-
CITY
STATE
ZIP
(
)
-
TELEPHONE NUMBER
EMAIL ADDRESS
2
OWNER INFORMATION:
Provide information about the person or company for which you want us to do an unclaimed funds search.
______________________________________________
_____________________________________________ ____________
OWNER’S LAST NAME (OR COMPANY NAME)
FIRST NAME
M.I.
________________ /_________________ /________________
________________________________________________________________________________
OWNER’S BIRTHDATE (IF KNOWN)
OWNER’S TAXPAYER IDENTIFICATION NUMBER (SSN/FEIN)
List current and previous addresses for the person or company named above:
(A)
_______________________________________________________________________________________________________________________________
STREET ADDRESS
________________________________________________________________
_________________
_________________________________
CITY
STATE
ZIP
(B)
______________________________________________________________________________________________________________________________
STREET ADDRESS
________________________________________________________________
_________________
_________________________________
CITY
STATE
ZIP
If No, provide Date of Death
Is this person living? (Y or N)
What is your relationship to this individual?
Enter the ITEM DETAILS (from the Internet search results) below, if known:
OUF CODE
3
CLAIMANT CERTIFICATION:
Please sign and have the statement below notarized.
I hereby claim funds held by the NYS Office of Unclaimed Funds. I/We hold the NYS Comptroller harmless from any loss
due to the payment of this claim. Under penalty or perjury, I certify that the number shown is my correct Taxpayer
Identification Number.
-
-
CLAIMANT’S SIGNATURE
CLAIMANT’S TAXPAYER IDENTIFICATION NUMBER (SSN/FEIN)
Please complete this form and mail it to:
Sworn to me this ______________ day of ____________ 20_________
Office of Unclaimed Funds
__________________________________________________________
_
110 State Street
NOTARY SIGNATURE
Albany, NY 12236

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