ADOR 10690 (5/21) Page 1 of 2
Property ID Number or a brief description of the property you are claiming
Original Property Owner’s Name
Original Property Owner’s Social Security Number or Tax Identification Number
Original Unclaimed Property Owner’s Address as reported by the Holder
Claimant’s Name
Same as above
Claimant’s Social Security or Tax Identification Number
Same as above
Claimant’s Date of Birth
Email Address
Telephone Number
Joint Owner’s Name
Not applicable
Joint Owner’s Social Security Number
Joint Owner’s Date of Birth
Address where you would like correspondence, including payment sent
City or town
ZIP Code
In consideration of the payment or delivery of unclaimed property as a result of this claim, I agree to indemnify the State of Arizona and hold
it harmless for and from all claims and loss, cost, damages and expenses that the State of Arizona may sustain by reason of turning over
the said property and by reason of its refusal hereafter to pay said property or any part thereof to any other person(s). I agree that if, for any
reason, it is found that I am not entitled to payments I receive as a result of this claim or I receive duplicate payment, I will return the funds
to the Arizona Department of Revenue within 15 days of demand. I swear and attest that all claims, assertions and signatures made in
this claim are true and material and that all photocopies I have or will provide are the same as the original documents. Furthermore, I swear
and acknowledge that any false statement made in this claim subjects me to penalties related to perjury and the subornation of perjury.
Claimant’s Signature
Claimant’s Signature
20 , BY:
Arizona Department of Revenue
Claim for Unclaimed Property - Original Owner
Mail to: Arizona Department of Revenue • Unclaimed Property Unit • PO Box 29026 • Phoenix, AZ 85038-9026
Email to: • This form requires a physical signature.
You must read page 2, which may be on the reverse side, before completing this form.
Unclaimed Property Hotline: (602) 364-0380 or outside the Phoenix area toll free: (877) 492-9957
For additional information see our website
ADOR 10690 (5/21) Page 2 of 2
Arizona Department of Revenue
Claim for Unclaimed Property - Original Owner
This form should only be used to claim property of which you are the original owner.
If you are claiming property as the heir or beneciary of a deceased owner (Form 600B), the agent of an entity (Form 600C) or the agent
of a living owner (Form 600D), you must complete the appropriate form.
Section 1 of page 1
Regardless of how you answer this Section, we will do a complete search of our database to identify and work to return
all unclaimed property belonging to the pertinent owner.
In this section, we ask that you please provide the property ID or a brief description of the property you are claiming. It is not required
to complete this section but we ask, if known, that you provide the property ID, if not known it is not required nor helpful to collect this
number. If you do not know the property ID number, but are looking for a specic lost asset, it is helpful to give us a brief description,
such as, “Southwest Cactus Wren Federal Credit Union Money Order Check #1008 321 6587” or “IRA funds from employer Jackson
and Lynch Welding”. Lastly, if you simply wish to collect all miscellaneous unclaimed property you may leave the section blank.
In the remaining questions in this section, you are required to provide the name of the individual you believe to be the owner, this
may be your name, and if known, the address, and tax ID number reported by the business or entity that remitted the property to the
State of Arizona. If unknown you may leave this Section blank.
Section 2 of page 1
It is very important that you complete this Section fully and accurately. You are required to provide us with your current or correct
name and your current/correct contact information. If you provide an email address, we will provide you with a receipt of your claim
with 15 to 20 business days of receipt; this information is no longer provided in hard copy. Providing an email address also expedites
communication and helps us more eciently serve you. The address that you record in this Section will be the address that payment will
be sent to should your claim be approved.
Section 3 of page 1
You must sign and date the form, we require a physical signature. In this section, please read the declarations carefully. There is
a notary section under the signature, you may choose to have the form notarized or provide a legible photocopy of valid government
issued photo identication; such as a driver’s license or passport. If there are joint owners, they must also sign the claim form (see
evidence requirements below for all joint owner exceptions).
You must provide proof of your identity as the claimant. Please provide a clear copy of ocial photo identication or have your
signature on the claim form notarized. If your name has changed since the property was reported to the State of Arizona, you must
provide verication of your name change, such as, a court order, marriage license or divorce decree.
You must provide proof of ownership. The Arizona Unclaimed Property Section does not release funds based on name similarity
alone, must provide a match to another reported factor, most commonly social security number or match to the reported (not current)
Provide proof that you lived at or received mail at the address reported to the State of Arizona as the last known address of the
original owner. If you do not know what address was reported to the State of Arizona, you can complete an inquiry at www. Acceptable proof includes; the original nancial instrument, a statement from the entity that originally held the
asset, a canceled envelope addressed to you, a credit report, lease/mortgage, property/income tax documentation, school/military
records, past government issued identication or utility bills/statements. Please see our website: for
a full list of acceptable proof. If you cannot nd acceptable proof or do not know the reported address you may provide proof of your
social security number and we will attempt to connect you to the reported address.
Provide proof of your social security number. Providing your Social Security number (SSN) is optional. However, if you choose not to
provide your SSN, there may be insucient information available to determine whether you are the owner of the unclaimed property
held by the Section and in some cases may result in your claim being denied. If you provide your SSN, the Section will only disclose
it to employees involved in paying your claim and to the federal government as required by law.
Joint owners must le together unless:
• One of the owners is deceased. In this case, a copy of the joint owner’s death certicate is required.
• The owners are now divorced. In this case, a certied copy of the divorce decree and complete property settlement are required.
The owners have lost contact. In this case, a notarized statement that conrms that the owners had no marital relationship, and have
lost all contact is required.
Please be aware that each claim is unique and that once your claim is received, the Section may need to request additional information
and will allow you an opportunity to provide the additional evidence rather than denying your claim. If you have any questions or
cannot provide the evidence requested we recommend that you complete the claim form and submit the evidence, you can
provide, along with a note explaining your circumstances. A claims specialist may be able to clarify and assist you with the evidence
Mail to: Arizona Department of Revenue • Unclaimed Property Unit • PO Box 29026 • Phoenix, AZ 85038-9026
Email to: • This form requires a physical signature.
For additional information see our website •