Unclaimed Property Inquiry Form - Oregon Department Of State Lands (Page 2 of 2) in pdf

Unclaimed Property Inquiry Form - Oregon Department Of State Lands Page 2

UNCLAIMED PROPERTY

INQUIRY FORM

Claimant(s) Name: ________________________________________________

Claimant(s) Address: ______________________________________________

City, State, Zip Code: ______________________________________________

Previous married names, or

maiden name if applicable: _________________________________________

Address of record, or

Previous address if applicable: ______________________________________

Social Security Number or FIN:* _____________________________________

I/We declare under penalty of perjury and/or mail fraud that to the best of my knowledge

I/we are entitled to the assets of this claim, and agree to indemnify the Oregon

Department of State Lands (DSL) and hold it harmless for and from all claims, loss,

costs, damages and expenses that DSL may sustain by turning this asset over to me/us,

or of its refusal to pay this asset or any part of it to any other person or persons.

Signature:________________________________________________________

Daytime Telephone #: ______________________________________________

Social Security #: __________________________________________________

Signature:________________________________________________________

Daytime Telephone #: ______________________________________________

Social Security #: __________________________________________________

State of ___________________________________________

County of _________________________________________

Signed or attested before me this _____ day of ____________

by _______________________________________________

__________________________________________________

Notary Public for: ____________________________________

My Commission Expires: ______________________________

*Note: Although you are not legally required to provide your Social Security number, we

request that you do so voluntarily to assist us in determining whether we are holding

property for you.

FOR OFFICE USE ONLY

Reviewed by _________ Date _________ Approved by _________ Date _________

$ ___________ V# ___________ Stock/SDB Sent _________ SSN ____ ADD ____

Unclaimed Property Inquiry Form - Oregon Department Of State Lands Page 2