Unclaimed Property General Claim Form
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1UNCLAIMED PROPERTY
GENERAL CLAIM FORM C
Claimant’s Name: __________________________
SSN: ___________________
Address: _________________________________________________________
City: ____________________________
State: _____
Zip: _____________
Day Time Phone (Including Area Code): (_____)____________________
Please indicate your filing status below; please note that failure to provide the requested
information will result in this Claim Form being returned to you:
HEIR. If you are an heir to the owner, send a copy of probated will, court order, OR affidavit of heir
ship listing heirs and current addresses, AND a copy of the death certificate of the owner. Also
provide the Deceased Owner’s information below.
TRUSTEE OR GUARDIAN. If you are a trustee or guardian to the owner, send copy of documents
establishing guardianship of trust. Also provide the Deceased Owner’s information below.
EXECUTOR OR ADMINISTRATOR. If you are an Executor or Administrator for the owner’s
estate, send a copy of the death certificate AND Letter of Administration OR Testamentary dated
within 90 days of filing this claim. Also provide the Deceased Owner’s information below.
OFFICER OF THE ORGANIZATION. If you are an Officer, send current documents establishing
your authority to act for the Organization.
PARENT. If you are the Parent of the owner, who is under age 18, attach a copy of the minor’s birth
certificate and proof of social security number.
DECEASED OWNER INFORMATION:
Name: __________________________________
SSN: ___________________
CERTIFICATION
I, the above named Claimant, hereby certify that this claim for property, presumed abandoned, is
valid and just. That all statements herein are true and correct, and that upon payment of this
claim said Claimant will indemnify and hold harmless the State of Texas, the City of Brenham,
and their Officers and Employees, from any damages, claims or losses of any kind resulting from
the payment of the above described property.
________________________________
_____________
Agent/Owner Signature
Date
The Texas Legislature allows for a handling fee to be charged for unclaimed property claims; however, there will be
NO handling fee if your claim is not paid. The amount of the handling fee will not exceed 1% of the dollar amount of
the claim. If a handling fee is assessed, it will be deducted from your total claim amount at the time payment is
made. Payment will be made within 90 days from receipt of a completed Claim Form and proof of ownership.
LEAVE THIS AREA BLANK
Claimant:
Claim Amt.:
Fee(s):
Net Amount:
By:
By
City Secretary
Finance Director
Date:
Date
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