Owner Claim Form - Louisiana Department Of Revenue
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1S
L
TATE OF
OUISIANA
D
R
EPARTMENT OF
EVENUE
Owner Claim Form
M. J. “M
” F
, J
.
J
N
K
IKE
OSTER
R
OHN
EELY
ENNEDY
Unclaimed Property Section
G
S
OVERNOR
ECRETARY
Post Office Box 91010
Baton Rouge, Louisiana 70821-9010
1-888-925-4127 • (504) 925-7407 • TDD(504) 925-7533
Claim of owner(s) to any property delivered to the Administrator
pursuant to the Unclaimed Property Act R.S. 9:151-181
A. Claimant name:
Original owner (required):
Last name, first, middle
Last name, first, middle
Address
Address
(
)
Owner’s Social Security Number/Tax ID
Daytime telephone number
B. Information about company or organization who held these funds (if known)
Name of company or organization
Address
City, State, ZIP
C. Property claimed
Identifying/Account Number of property being claimed
Type of property
Amount
D.
Attach a copy of your driver’s license and any documentation, instrument,
of former address as listed on the account, or provide other documentation
which supports your claim of ownership. You must provide adequate
or passbook pertaining to the item for which claim is being made. If the
instrument, passbook, or deposit book (issued by organization) has been
documentation or your claim may be denied.
lost, stolen, or destroyed, please support ownership by submitting proof
E. Affidavit:
All claimants to the above property must sign this claim form below. If your
The named claimant hereby certifies that this property presumed
claim has a value of $50 or more, you are required to have this form
abandoned is valid and just, that all statements are true and correct, and
notarized. If the claimant is a corporation, this claim must be executed by
that upon payment of this claim, said claimant will indemnify and hold
the chief fiscal officer of a public corporation, or an officer of a private
harmless the State, its officers and employees, from any other valid
corporation or unincorporated association If the claimant is a partnership,
claims to said property or from any loss resulting from the payment of said
this claim must be executed by a partner.
claim.
Subscribed and sworn to before me this
Signature(s) of claimants:
day of
, 19
Notary Public
Parish/County, State
My commission expires:
For office use only
Report year: ________
Holder ID ______________________
Property ID/Claim number _____________________
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