Inactive Or Dissolved Company With Estate Affidavit For Name/address Change Request Form printable pdf download

DEPARTMENT OF FINANCIAL SERVICES

Division of Rehabilitation and Liquidation

INACTIVE or DISSOLVED COMPANY with ESTATE AFFIDAVIT for NAME/ADDRESS CHANGE REQUEST

After being duly sworn, the Affiant states as follows:

My name is __________________________. I have personal knowledge of the matters set forth in this

affidavit, and if called to testify would do so as set forth herein.

I am _____ years of age.

My current address is ____________________________________________________________.

(*Insert name of Inactive or Dissolved company)

*________________________________________ is currently dissolved. (corporations, only)

I was the sole owner and proprietor of *__________________________________________.

*_____________________________________ has not been subject to a U.S. Bankruptcy Code proceeding.

No rights or interest in *__________________________________have been subject to disposition in a

dissolution of a marriage proceeding.

(*Insert deceased claimant’s name)

I am the sole beneficiary of the estate of *_________________________________________________.

My relationship to *_____________________________________ is ___________________________.

(*Insert Receiver Claim Number and name of Receivership Company from the request form)

10. I am the sole person who is entitled to any funds resulting from receivership id# *_______________ in the

estate of (not deceased person) *____________________________________________________________.

11. I agree to allow my name and address to be provided to any subsequent claimants who come forward with

proof to claim entitlement to these funds.

12. I agree to hold harmless the Department of Financial Services and the Division of Rehabilitation and

Liquidation should subsequent claimants come forward with proof to claim entitlement to these funds.

I swear or affirm that I am the claimant referenced in the mailing address on this form and/or am authorized to

sign this form on the claimant's behalf. I further swear under penalty of law that all information contained on this

form as well as all attachments are true and correct to the best of my knowledge.

___________________________________ _______________________________________________

(Affiant Signature)

(Affiant Printed Name)

State of __________ County of ___________

Sworn to and subscribed to me by _____________ on this ____day of _______, 20___.

Notary Signature ____________________________

R6-13 (K) Name-Address Inactive or Dissolved Company Estate Affidavit 8/2011

Inactive Or Dissolved Company With Estate Affidavit For Name/address Change Request Form