Unclaimed Property Claim For Reimbursement Form - Alaska Department Of Revenue
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1UNCLAIMED PROPERTY CLAIM FOR REIMBURSEMENT
ALASKA DEPARTMENT OF REVENUE
TAX DIVISION
UNCLAIMED PROPERTY SECTION
PO BOX 110420
JUNEAU, AK 99811-0420
(907) 465-3726
USE THIS FORM TO REQUEST REIMBURSEMENT OF:
1. FUNDS YOU RETURNED TO THE OWNER AFTER YOU PAID IT TO THE STATE OF ALASKA
2. FUNDS YOU PAID TO THE STATE OF ALASKA IN ERROR
Reporting Company Information: (Please TYPE or Print Legibly)
Company Name:
Federal Tax ID#:
Contact Person:
Reimbursement Amount:
Mailing Address:
Contact
Phone Number:
ORIGINAL Information Reported to the State of Alaska:
Owner Name:
Year Property Reported:
Total Amount Reported
Owner SSN:
For Report Year:
Owner
Mailing Address:
Property Type:
WAS THE OWNER INFORMATION REPORTED IN AN AGGREGATE AMOUNT? (Circle YES or NO)
Reason For Reimbursement Request:
A. Monetary property has been refunded to the owner (show proof).
Proof Required:
B. Customer’s account has been reinstated (show proof).
If you have returned property to the
C. Property was reported to the State of Alaska in error (explain below).
owner or reinstated an account, you
D. Owner has requested return of property other than money.
must show proof. Attach a copy of both
E. Other:
sides of the cancelled check issued to
the owner or the account statement. For
a traveler’s check claim, attach the
original or a copy of the check. If the
claim is for payment made on a money
order or negotiable instrument, attach a
copy.
I declare under penalty of perjury that I have examined this claim and that to the best of my knowledge and belief it is true,
correct, and complete.
Signature: _________________________________ Print Name: ___________________________ Date: __________
SUBSCRIBED AND SWORN to before me this _______ day of ________________, 20_____.
Signature __________________________________ Notary Public, State of _____________
Print Name __________________________________ My Commission Expires: ___________
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