Fillable CLAIM FORM Office of the State Treasurer P. (Mississippi)

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CLAIM FORM Office of the State Treasurer P. (Mississippi)

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Office of the State Treasurer
P. O. Box 138, Jackson, MS 39205
Telephone (601)359-3534
www.treasury.ms.gov
David McRae
State Treasurer
Lee Youngblood, Director
Unclaimed Property Division
CLAIM FORM
Property ID#_____________________
Instructions: Please read UP Checklist for Required Documentation carefully to complete this form.
Submit all required documentation - without it we cannot process your claim request. Each claimant
must submit a copy of an official photo ID & copy of Social Security card with this claim form.
A. Claimant’s
name and current address: B. Original owner’s name as listed on
website or letter:
_____________________________________
_______________________________________
_____________________________________ _______________________________________
_____________________________________ _______________________________________
Claimant’
s Social Security number or Corporation’s FEIN tax ID: ________________________________
Claimant’s daytime phone #: ____________________ E-mail: __________________________________
C. If your name is different from the name shown in Section B, please explain why:
Marriage
/Divorce…………..
Attach a copy of filed papers.
Owner is de
ceased……….Your relationship to deceased: _______________________________
Corporation/Business……Your position with company: ___________________________________
Other……………………………..Please explain: __________________________________________
Subscribed and sworn to before me this Affidavit: The named claimant hereby certifies that this
claim for property presumed abandoned is valid and just,
_____ Day of ___________________, 20___ that all statements herein are true and correct, and that
upon payment of this claim said claimant will indemnify
_____________________________________ and hold harmless the State, its officers and employees,
Notary Public County/State from any other valid claims to the said property.
My commi
ssion expires __________________
Signature of Claimant - Must be Notarized
If signed by 2 claimants, both signatures must
be separately notarized.
============
================= _____________________________________
_____ Day of ___________________, 20___
_____________________________________
_____________________________________
Notary Public County/State
My commis
sion expires __________________
Please Allow 8 Weeks For A Response.
This is a free service provided through
the Office of the State Treasurer.
Unclaimed Property Checklist for
REQUIRED DOCUMENTATION
Telephone (601)359-3534
www.treasurerlynnfitch.com
If you are an individual claiming property, you must provide:
Photo ID: Copy of a driver’s license, passport, military ID card or other official card.
Social Security Number(s): Copy of the claimant’s SSN card.
Proof of Address: Send proof of address that was reported to the State.
Name Change: If owner’s name has changed for any reason, submit marriage license, divorce decree or legal
document showing name change.
Claim Form: Notarized signature of individual(s) claiming property.
Minor: If the owner is a minor, send copy of minor’s birth certificate.
If the owner is deceased, you must also provide:
Death Certificate: Send a copy of the owner’s death certificate and any deceased heir’s death certificate.
Will/Obituary/Affidavit of Death: If the owner or the owner’s heirs are deceased, please submit a copy of
the owner’s filed will, if there was one. If none exists, send a copy of the obituary or funeral program showing
all heirs. If there was no obituary or funeral program, each claiming heir must complete a notarized Affidavit
of Death available on our website
.
Is the estate open or closed? Please notate this on the claim form. If the estate is open, we pay the
estate in care of the executor. If the estate is closed, we must split the funds between all legal heir(s). Each
heir needs to complete a separate claim form.
If you are claiming for a corporation or business, you must provide:
Photo ID: Copy of officer’s company ID badge, driver’s license, passport or other official ID card.
Employer FEIN Tax Number: Send copy of FEIN for the corporation/business.
Proof of Company Position: Examples include a business card or letterhead listing officer.
Proof of Address: Send proof of company address that was reported to the State.
Is business open or dissolved? If business is open, we will pay the business. If the business is dissolved,
send legal proof of each owners’ name and the percentage of the company each owned.
Claim Form: Notarized signature of company owner/officer.
PLEASE NOTE: We may require additional documentation to process your claim.
David McRae
State Treasurer
Lee Youngblood, Director
Unclaimed Property Division
Revised March 14, 2017
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CLAIM FORM Office of the State Treasurer P. (Mississippi)

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Completed 18 July 2020

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