Holder Claim Form - Oregon Department Of State Lands
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1Holder Claim Form
Claim to recover Property Received by the State of Oregon Pursuant to Oregon Revised Statute Chapter 98
Oregon Department of State Lands
775 Summer Street NE Suite 100
Salem, OR 97301-1279
(503) 986-5289 ~ FAX (503) 378-4844
Holder Name
Street address
City State Zip
Telephone
1.
On behalf of the above-named firm, I hereby request reimbursement for $____________________, which
was paid to the rightful owner of an account remitted to the State of Oregon on ____________________
The type of asset paid to DSL is checked below. If the claim is for cashier’s check, money order or any
2.
other negotiable instrument, the original instrument is attached.
3.
Claim Information:
Amount Reported
Year Reported
ID Number
Property
Property Description
In
Sequence#
Type
Aggregate?
Yes No
4.
The owner name(s) listed on the report: ______________________________
(A list may be attached if claiming multiple instruments or accounts)
5.
If the asset was remitted to the Department of State Lands in error, please attach a detailed explanation
6.
Proof that the owner has been paid is attached.
On behalf of the above named holder, I guarantee that all endorsements are genuine and authorized, and if any
endorsements are missing, I agree, upon notice of any adverse claim, to defend the Department of State Lands
(DSL) against the same, and to discharge the same, if valid. I agree, upon payment of the above described asset, to
indemnify DSL and hold it harmless from all claims and loss, demands, costs, damages, attorney fees, and other
expenses which DSL may sustain by reason of turning over said amount to the holder and by reasons further of its
refusal to pay the said amount to any other person or persons.
I, ______________________________, being duly sworn, state that my position in the above named
(Print or Type Name)
firm is
, and I am authorized to execute this claim form. It is, to the best of
my knowledge and belief, true, correct, and complete.
______________________________
(Signature)
State of ___________________________________________
County of _________________________________________
Sworn or affirmed before me this _____ day of ____________
by _______________________________________________
__________________________________________________
Notary Public for: ____________________________________
My Commission Expires: ______________________________
Revised 11/2011
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