Unclaimed Monies Claim Form
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1Auditor – Fiscal Services Unclaimed Monies Claim Form
Claimant Information
Claimant Name
Claimant Address
Claimant City/ State/ Zip
Claimant Home Phone Number
Claimant’s Date of Birth
Social Security Number or FEIN
Are you the original owner of the
If no, what is your relationship to the
Reason for claiming funds in place of owner?
funds?
owner?
Amount of funds to be claimed
Description of funds
Failure to complete this Claim Form, and/or provide the required documentation, will result in your claim being returned to you.
Original Owner must provide:
•
A clear copy of claimant’s photo identification (i.e. Driver’s license, employment ID, passport or state ID) and Social
Security Card. If name is different, then proof of claimant name must be provided;
•
If the address is different than Driver’s license or State ID, then proof of claimant address must be provided (i.e. a utility bill,
bank statement, mortgage/rent statement);
•
Claims over $100 must be signed in the presence of a Notary Public;
•
If Original Owner is a business, documentation supporting Federal Employee Identification Number must be provided.
Third party claimant must provide:
•
A clear copy of claimant’s photo identification (i.e. Driver’s license, employment ID, passport or state ID) and Social
Security Card. If name is different, then proof of claimant name must be provided;
•
A clear copy of third party claimant’s photo identification (Driver’s License, employment ID, passport or state I.D.) and
Social Security Card. If name is different, then proof of claimant name must be provided;
•
Claims over $100 or more must be signed in the presence of a Notary Public;
•
A completed Power of Attorney signed by original owner and third party claimant. Power of Attorney must also be signed in
the presence of a Notary Public;
•
If Original Owner is a business, documentation supporting Federal Employer Identification Number must be provided.
Unclaimed funds involving an estate/deceased claimant:
•
A clear copy of third party claimant’s photo identification (Driver’s License, employment ID, passport or state I.D.) and
Social Security Card. If name is different, then proof of claimant name must be provided;
•
A death certificate must accompany request;
•
A copy of the will or certified Letter of Authority from the appropriate County Probate Court, appointing claimant as
Executor or Administrator of decedents estate.
Certification and Notary
All claim forms must be signed. To claim funds $100 and over, this form must be notarized.
The undersigned claimant certifies that he/she is the proper claimant in the foregoing claim; that he/she read the foregoing claim and
knows the contents thereof; that the same is true and correct to his/her knowledge that the information and documentation are
unaltered and not fraudulent; and, that the claim is valid, and unpaid. The claimant understands that presentation of a fraudulent claim
may result in criminal proceedings. The claimant further declares that upon payment of this claim, he/she will indemnify and hold
harmless, Butler County officers and employees from any damages, claims or losses of any kind resulting from payment of the above
claim.
Claimant Signature__________________________________________________Date_________________
Print Name of Claimant ___________________________________________________________________
Co-Claimant Signature _______________________________________________Date_________________
Print Name of Co-Claimant_________________________________________________________________
Sworn to and subscribed before me the _____________day of ________________Year_________________
Notary Signature__________________________________________________________________________
State of ______________________________________County of___________________________________
Notary Stamp and Seal
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