Unclaimed Property Holder Claim Form
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1**For office use only**
Approved
User
Date
1st Level
l
2nd Leve
rd
3
Level
UNCLAIMED PROPERTY HOLDER CLAIM FORM
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, or to return funds that have
been determined to no longer belong to the payee as originally reported pursuant to the Virginia
Unclaimed Property Act.
A. Contact person _________________________________
Phone number _________________________
e-mail address ______________________________________
B. Holder’s Name _______________________
Holder Federal I.D. No. ___________________
Holder’s Address
_________________________________________________________________________
C. Account Information About Payee(s):
Co-owner: __________________________________
______________________________________________
______________________________________________
le
Last Name
First
Midd
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.
The above noted item is due to be returned to the Holder for the following reason:
Payee has already been issued a replacement check or credited with this amount
Check was originally reported in error
Payee is no longer due these funds (explain)
The Holder hereby agrees to release and hold harmless the State Treasurer, its officers and
employees, from any loss resulting from the payment of this claim. The below named individuals
affirm that they are an authorized representative of the Claimant (Holder) in the foregoing claim,
that the statements in said claim are true to the best of their knowledge, and that they are authorized
to act on behalf of the Holder for purposes of claiming these funds. Further, the return of these funds
to the Holder releases the Department of the Treasury from any liability to the above named payee
for these funds
.
F. Must be signed by two principal officers or one officer and an authorized employee
______________________________________________
____________________________________________
Printed Name
(Title)
Signature
Date
______________________________________________
____________________________________________
Printed Name
(Title)
Signature
Date
G. Mail to:
Telephone: 804-225-2393 or 1-800-
Department of The Treasury
468-1088
Division of Unclaimed Property
P.O. Box 2485, Richmond, VA 23218-2485
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