Unclaimed Property Holder Claim Form - Virginia Department Of The Treasury
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1
2COMMONWEALTH OF VIRGINIA
DEPARTMENT OF THE TREASURY
**For office use only**
Division of Unclaimed Property
Approved
User
Date
P.O. Box 2478
1st Level
Richmond, VA 23218-2478
l
2nd Leve
Telephone: 804-225-2393 or toll free 1-800-468-1088
rd
3
Level
Rev. 6/2009
UNCLAIMED PROPERTY HOLDER CLAIM FORM
FOR HOLDER USE ONLY
Purpose:
To reimburse Holder for property delivered to the State Treasurer, and subsequently returned to the rightful owner, or to
refund an account that has been reported in error, pursuant to the Virginia Unclaimed Property Act.
A. Contact person ________________________________
Phone number _________________________________
e-mail address ____________________________________________
B. Holder’s Name ________________________________
Holder’s Address ______________________________
Holder Federal I.D. No. _______________________________
______________________________________________________
C. Account Information About Reported Owner(s):
Co-owner:
_____________________________________________
______________________________________________
Last Name
First
Middle
Last Name
First
Middle
______________________________________________________________________________________________
Number and Street
City
State
Zip
D. Property Type/Description:
Date Reported to State
____________________
Media Used:
Diskette/CD
FTP Upload
Total Amount of Report
____________________
Hardcopy/Paper
Page number ____________
Amount requested
____________________
Property Reported:
Individually
in Aggregate
E. ATTACH COPY OF CANCELLED CHECK OR RECEIPT SHOWING PAYMENT TO ORIGINAL OWNER
OR SUBMIT PROOF OF REACTIVATION OF ACCOUNT or EXPLAIN WHY YOU CONSIDER THIS
ACCOUNT TO HAVE BEEN REPORTED IN ERROR.
F. The holder hereby agrees to release and hold harmless the State and the Treasurer, its officers and employees, from
any loss resulting from the payment of this claim. The below named individuals swear and affirm that they are
representatives of the Claimant (holder) in the foregoing claim and that the statements in said claim are true to the best
of their knowledge.
Must be signed by two principal officers or one officer and an authorized employee.
_____________________________________________
____________________________________________
Typed name
(Title)
Signature
Date
_____________________________________________
____________________________________________
Typed name
(Title)
Signature
Date
Please Note: In order to be valid, your original signature must appear on this document. Copies or faxed
reproductions of signatures are not acceptable.
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