Unclaimed Property Holder Claim Form With Filing Instruction
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1
2**For office use only**
Approved
User
Date
1st Level
UNCLAIMED PROPERTY HOLDER CLAIM FORM
l
2nd Leve
rd
3
Level
ID # ____________
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 _________________________
Holder’s Name _________________________________
Holder Federal I.D. No. __ _________________
Holder’s Address
_________________________________________________________________________
E-mail address ______________________________________
B. Report Information: Date Reported to State_______________ Total Amount of Report __________________
Total Amount of refund requested ______________
C. Select type of refund request:
1. Over-remittance on report, not related to specific account(s)
Remittance did not agree with reported amount
Estimate remittance paid was greater than report amount
Supporting documentation for this refund is attached.
OR
2. Requesting refund on specific account reported as:
_____________________________________________
______________________________________________
le
Second Owner
Owner Last Name
First
Midd
Last Name
First
Middle
______________________________________________________________________________________________
Number and Street
City
State
Zip
Attached supporting documentation for this refund:
Payee is no longer due these funds – please explain
Account was reported in error - please explain
Payee has already been issued a replacement check or credited with this amount
a. back and front copy of cancelled check or receipt showing payment to original owner or
b. proof of reactivation of account.
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
D. Must be signed by two principal officers or one officer and an authorized employee
_________________________________________
___________________________________________
Printed Name
(Title)
Signature
Date
_________________________________________
___________________________________________
Printed Name
(Title)
Signature
Date
E. Mail to:
Department of The Treasury
Telephone: 804-225-2393 or 1-800-468-1088
Division of Unclaimed Property
P.O. Box 2485, Richmond, VA 23218-2485
Please Note: In order to be valid, your original signature must appear on this document. Copies or faxed
reproductions of signatures are not acceptable.
Rev 01/2013
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