Claim Form - Minnesota Department Of Commerce (Page 2 of 2) in pdf

Claim Form - Minnesota Department Of Commerce Page 2

INSTRUCTIONS ENCLOSED

CL AIM ID

Unclaimed Property Division

(Office Use On ly)

85 7th Place East, Suite 600

St. Paul, MN 55101

To file a claim, complete this form and return it with the

MINNESOTA

required documentation to our office.

DEPARTMENT OF

COMMERCE

B. CLAIMANT INFORMATION

A. REPORTED PROPERTY INFORMATION

1. Claimant Name(s):

1. Property ID

2. Original Owner(s):

3. Original Owner's Address

2. Mailing Address

4. Type of Property

5. Amount of Property

5. Zip Code

3. City

4. State

6. Company Reporting Property

6. Daytime or Message Phone

7. Claimant(s) Social Security Num. or FEIN

C. PROOF OF OWNERSHIP

The following must be included with this form:

* Must include SSN proof for ALL OWNERS *

9. If response to #8 is no then:

8. Are you the original

Clear copy of current driver's license or clear

What is your relationship to the

owner of the property?

copy of other legal photo identification, and

owner?

Yes

Proof of Social Security Number or FEIN, and

Proof of the original owner's address as listed above

* For Office use only *

Claim Amount:

in section A (Examples of documentation enclosed.)

* See instructions for additional information on proof of ownership *

D. AFFIDAVIT

Must be signed in Presence of a Notary Public

The named claimant hereby certifies that he/she has a legal and

I AFFIRM, UNDER THE PENALTIES OF PERJURY, THAT THE

equitable interest in the unclaimed property identified above and agrees

FOREGOING REPRESENTATIONS ARE TRUE.

that he/she will indemnify and hold harmless the State of Minnesota, its

officers, and employees from any other valid claim to such unclaimed

_____________________________________________

property or from any loss resulting from the payment of the claim.

Signature Of Claimant

_____________________________________________

Signature of Joint Claimant

Notary Stamp

Sworn to and subscribed before me this_______day of _________________, 20 _____

Notary Public for the State of ________

My Commission expires: __________________

Notary signature _______________________________

If you have questions in filing this claim, please read the enclosed instructions.

•

Unclaimed Property

Twin Cities or Out of State (651) 296-2568

In State, Long Distance (800) 925-5668

TTY (651) 297-3067

INSTRUCTIONS ON ENCLOSED

Claim Form - Minnesota Department Of Commerce Page 2

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