Holder Request for Reimbursement - Free Download
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Holder Request for Reimbursement
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 __________________, 2012 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)____________________________________________
Signature of Holder Representative _______________________________________ Date_______________
Form also available at NAUPAs Web site www.unclaimed.org
HOLDER REQUEST FOR REIMBURSEMENT
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