California State Controller's Office Unclaimed Property

Claim Affirmation Form

Each of the undersigned claimants certifies, under penalty of perjury, that the claimant has read the claim and knows the contents thereof and that the claimant is the owner of the said claim and the person entitled to receive the money and property set forth in said claim.

Each claimant agrees to indemnify and hold harmless the State, it's officers, and employees from any loss resulting from the payment of said claim.

CURRENT INFORMATION AND SIGNATURE MUST BE PROVIDED FOR EACH CLAIMANT, OR THE CLAIM WILL BE RETURNED

1st Claimant

LAST NAME OR BUSINESS

FIRST NAME

MIDDLE INIT.

SSN or FEDERAL TAX ID

PROPERTY ID
004377864

CURRENT MAILING ADDRESS

CITY

STATE/PROVINCE

ZIP

COUNTRY

DAYTIME PHONE

CLAIMANT OR AUTHORIZED AGENT SIGNATURE

DATE

2nd Claimant

LAST NAME OR BUSINESS

FIRST NAME

MIDDLE INIT.

SSN or FEDERAL TAX ID

PROPERTY ID
004377864

CURRENT MAILING ADDRESS

CITY

STATE/PROVINCE

ZIP

COUNTRY

DAYTIME PHONE

CLAIMANT OR AUTHORIZED AGENT SIGNATURE

DATE

YOUR SIGNATURE(S) MUST BE NOTARIZED IF THE CLAIM AMOUNT IS $1,000, OR MORE.
ALL STOCK CLAIMS MUST BE NOTARIZED

For claims filed for a business, the authorized owner's signature is required. For claims filed for an estate or trust, the signature of the executor, administrator or attorney is required.

Subscribed and sworn to before me this ______________ day of _____________ year of ____

________________________________
Notary Public in and for the County

of ________________, State of ___________________

PRIVACY NOTIFICATION

The Information Practices Act of 1977 and the Federal Privacy Act require this Division to inform you that your Social Security number and other documents are requested for property identification and processing of your claim.

You have the right to view your records at this office by sending a request to: Chief, Bureau of Unclaimed Property, P.O. Box 942850, Sacramento, CA 94250-5873.

FOR CALIFORNIA STATE CONTROLLER'S OFFICE USE ONLY

ANALYST

SUPERVISOR/MANAGER

ADMINISTRATION

PREPARED BY

DATE

APPROVED BY

DATE

REVIEWED BY

DATE

APPROVED BY

DATE

DOC

INSTRUCTIONS FOR FILING A CLAIM

Using this instruction sheet, determine and provide the appropriate documents in order to process your claim, and return them with your completed Claim Affirmation Form.

All claimants must review SECTION A for required documentation. If you are an HEIR or BENEFICIARY of the deceased owner, refer to SECTIONS A & D.

SECTION A: CLAIMANT IDENTIFICATION

Property ID:

(1)

Copy of a photo identification (e.g., driver's license, state identification card, passport, etc.) for each claimant;

(2)

Copy of each claimant's Social Security card or any other document showing the claimant's Social Security number (e.g., federal or state income tax return or pay stub, etc.);

(3)

Original passbook, check, stock certificate, or instrument identified on the front page of this Claim Form under "Type of Property." If none of these items are available, proceed to SECTION B.

If you are providing items 1, 2, and 3, proceed to SECTION E.

SECTION B: LOST, STOLEN, OR DESTROYED INSTRUMENT

Property ID:

If the original passbook, stock certificate, check, or instrument has been lost, stolen, or destroyed, you must show proof that you once resided at the "Reported Address" indicated on the front page of the Claim Form.

(4)

Do you have any documents (e.g., utility bill, tax bill, bank statements, etc.) indicating that you or the owner currently reside or once resided at the "Reported Address" indicated on the front page of the Claim Form?

* YES, proceed to SECTION E.

* NO, proceed to SECTION C.

SECTION C: NO ADDRESS VERIFICATION AVAILABLE

Property ID:

If you are not able to provide evidence associating yourself or the owner with the "Reported Address" indicated on the front page of the Claim Form, you must submit the following proof of ownership:

(5)

Document (e.g., correspondence, statement, etc.) associating you or the owner with the business or bank listed on the front page of the Claim Form under "Reported By".

If you are providing item 5, proceed to SECTION E.

NOTE: IF ITEM 3, 4, OR 5 IS NOT AVAILABLE, YOUR CLAIM MAY BE DENIED.

SECTION D: DECEASED OWNER

Property ID:

If you are an HEIR of the deceased owner named on the account, you are required to submit ALL items under SECTION A, the death certificate of the deceased owner, PLUS one of the following documents:

(6)

Copy of Currently Certified Letters, dated within the past six months, appointing the Executor or Administrator of the decedent's estate, and the Estate Tax Identification number; or

(7)

Complete copy of the Court Ordered Distribution of the Decedent's Estate; or

(8)

If the distribution of the estate was not ordered by a court, a complete copy of the decedent's Will and/or Trust Agreement; and a completed Declaration Under Probate Code Section 13101 FORM; or

(9)

If no Will or Trust Agreement exists, a completed Declaration Under Probate Code Section 13101 form and a Table of Heirship form. You may obtain these documents at the State Controller's web site at http://www.sco.ca.gov/col/ucp/forms/index.shtml . You may also contact our office to request these forms.

If you are providing the death certificate and item 6, 7, 8, or 9, proceed to SECTION E.

SECTION E: SIGNED CLAIM FORM / AFFIRMATION

Property ID:

(10)

If the "Amount" (listed on the front page of this Claim Form) is $1,000 or more, or the "Type of Property" (listed on the front page of the Claim Form) is related to stock and mutual funds, complete, sign, and NOTARIZE the Affirmation.

(11)

If the "Amount" is less than $1,000, complete and sign the Affirmation.

Confirm that all required documents are included and send the entire package to the address on the front page of the Claim Form.

STEVE WESTLY
California State Controller

CLAIM FORM

Date:

Source:

Property ID Number:

Owner's Name:

Amount:

Type of Property:

Reported By:

Reported Address:

This is to inform you that, according to our records, you may be entitled to the money, the property, or the proceeds from any sale of the property listed above. If you are claiming this property or the proceeds, you must fully complete and return all required documents.

PLEASE NOTE THAT YOU MUST SIGN THE CLAIM AFFIRMATION FORM OR YOUR CLAIM WILL BE RETURNED.

In addition, you must include a copy of your driver's license that shows your current address and some form of verification of your Social Security number, such as a copy of your Social Security card or a tax return showing your name and Social Security number. If you do not have all of the items required, please send as much information as possible to prove this claim. If you are an heir, not a direct owner, provide a certified copy of the owner's Death Certificate and Will or a Final Decree of Distribution. Send these documents to:

State Controller's Office
Bureau of Unclaimed Property
P.O. Box 942850
Sacramento, CA 94250-5873

Once your package is received with all the required documentation, this office will be able to return your property or the proceeds from its sale to you. Due to the success of the Controller's Internet site, this office has received thousands of claims. Please do not contact this office to inquire about your claim's status unless it has been over 180 days since it was filed. Such calls will only delay payments. Thank you for your patience.

14-Int (Rev 09/2004)