*“Privacy Act of 1974 Disclosure: (1) the disclosure of your social security number on this form is voluntary; (2) it is solicited to aid the State Treasurer in determining whether you are entitled to claim
unclaimed property; (3) your social security number will not be shared with any other 3rd party, with the exception of the Accounting Division of the Department of Administrative Services. If you object to
the disclosure of your social security number, we will attempt to use alternative means for verication purposes; however, your claim may be rejected.”
Warrant Number:
Date of Warrant:
Claim Number:
Amount:
Date Mailed:
Date Filed:
Approved Denied
By:
By:
STATE TREASURER’S RECORD & RECOMMENDATION
PLEASE ATTACH EACH OF THE FOLLOWING:
Return To:
Photocopy of your valid Driver’s License
Photocopy or proof of your Social Security number*
List of owner’s former addresses for last 10 years
If owner is deceased, photocopy of death certicate and proof of your right to
represent the estate
.
.
.
.
State Treasurer
809 P Street
Lincoln, NE 68508-1390
Signature(s) of Claimant(s)
Notary stamp >>
Subscribed and sworn before me this day of
20 .
Notary Public
My Commission Expires
County, State
I do hereby swear or afrm, under penalty of perjury, that I am serving as a duciary of the Estate of ,
who died on the day of , .
Property ID Number(s) (if known):
Claimant’s Name and Present Address:
Claimant’s Social Security or Federal Tax ID Number*:Name of Owner as it appeared during your search:
“Claimant” means person claiming property.
“Owner” means name as listed with the State Treasurer.
Claimant is:
Original Owner
Guardian or Custodian
Executor, Administrator or Personal Representative
Heir(s) or Beneciary of Decedent
Other
Email Address: Daytime Telephone Number:
Owner’s Date of Birth:
Heir afdavit: Complete this portion of the form if you are claiming the property of a deceased person.
Day Month Year
Heir Name, Address, and Phone
Heir Name, Address, and Phone
Heir Name, Address, and Phone
Heir Name, Address, and Phone
If your claim includes shares of stock, your signature indicates that you swear or afrm under penalty of perjury that the stock certicates issued to the owner
have been misplaced, destroyed, or were never received and that these certicates have never been sold, pledged, hypothecated, or otherwise transferred. If at
any time in the future the certicates are located, you agree to surrender them immediately to the State of Nebraska.
If my unclaimed property contains shares of stock, I authorize the State of Nebraska to (check one)
Sell my shares and send me the proceeds (default)
Transfer the shares into my name (only applicable if you are the original owner of the shares, not an heir)
You must present valid ID for your claim to be processed.
This claim form must be signed and notarized. Each undersigned claimant, being rst duly sworn, deposes that, to the best of his/her knowledge, the
undersigned is/are the owner(s), heir(s) or have a rightful interest in the said abandoned property being held by the Treasurer of the State of Nebraska. Each
claimant also declares that all above information and attachments are true and complete documents. Further should any claim be made against the State
Treasurer regarding the said abandoned property and found to be of valid nature, the undersigned claimant(s) will reimburse the Ofce of the State Treasurer.
Attach documentary evidence that establishes the claimant as the rightful owner of the property. Include as much detail evidence as possible.
I am the of the decedent, and I assume responsibility to distribute lawfully this property, including withholding portions for payment of
all relevant estate and county inheritance taxes, to the following surviving heirs (list all names, relationships, addresses & phone numbers - Attach a separate
sheet if necessary). Further, I will indemnify the State of Nebraska, its ofcers and employees, from any loss resulting from the payment of this claim.
Check here if you would be willing to be interviewed about your unclaimed property for possible publication by the State Treasurer’s Ofce.
If claiming for a business, this claim form must be signed by a partner of a partnership; an ofcer of a corporation (include a corporate resolution naming ofcer
authorized to sign); or an ofcer of an unincorporated association.
How did you become aware of this property?
Unclaimed Property Newspaper Publication
Nebraska State Fair
Husker Harvest Days
Other Outreach (list event):
News Story (print/web/tv/radio)
Advertisement (print/web/tv/radio)
Facebook/Social Media
Friend or family member
Other
CLAIM TO STATE OF NEBRASKA FOR UNCLAIMED PROPERTY
