Claim for Abandoned Property
BETTY T. YEE
CALIFORNIA STATE, CONTROLLERS OFFICE
UNCLAIMED PROPERTY DIVISION
P.O. BOX 942850
SACRAMENTO, CA 94250-5873
SECTION I DESCRIPTION OF FUNDS, ETC., DUE OWNERS
DATE
HOLDER:
CONTROLLER’S ACCOUNT NUMBER
SECTION II REQUIRED PROOF MUST BE RETURNED WITH THIS FORM
The checked items below must be returned with this form in support of your claim. If any item(s) are not submitted, your claim package will be returned.
You may reopen this file by returning the claim form and all required documentation to this office.
1. ( ) NOTARIZATION REQUIRED - If claim amount is $1,000 or greater, or is stock, security property, or safe-deposit box
2. ( ) This claim form is to be signed by Claimant
3. ( ) Original savings account passbook or statement for account no.
4. ( ) Checking account statement for account no.
5. ( ) Original Amount
6. ( ) Original securities certificate(s) for shares of
(OR IF CONFISCATED BY TRANSFER AGENT OR SOLD, SUBMIT EVIDENCE OF THE TRANSACTION).
7. ( ) Document verifying owner's address was once:
8. ( ) Will and currently certified (within the last six months) Letters Testamentary appointing administrator and/or
executor (open estate) or certified copy of Final Decree of Distribution (closed estate) for the estate of:
9. ( ) If the estate was not probated, please execute the enclosed Declaration Under Probate Code Section 13101 and
Table of Heir ship (Table of Heir ship must be completely filled out and notarized).
10. ( ) CERTIFICATE of for
11. ( ) Birth, Death, and/or Marriage Certificate associating claimant(s) with owner of account.
12. ( ) Copy of document verifying your identity (i.e., driver's license, ID card)
13. ( ) Copy of document verifying your Social Security number or, if business, tax ID number.
14. ( X ) ALL CLAIMANTS MUST COMPLETE SECTIONS III, V, AND VII ON REVERSE.
15. ( X ) ALL INVESTIGATORS/HEIRFINDERS MUST COMPLETE SECTIONS IV AND V.
16. ( X ) After initial review, additional documents may be required.
ANALYST APPROVED: Date:
SUPV./MGR. APPROVED: Date:
ADMIN. APPROVED: Date:
CE-1 REV. 03/15 Page 1 of 2
CE-1 REV. 03/15
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SECTION III CURRENT MAILING ADDRESS (TO BE COMPLETED BY ALL CLAIMANTS)
(1) PRINT FIRST NAME
LAST
DAYTIME PHONE
( )
STREET ADDRESS
CITY
STATE
ZIP CODE
(2) PRINT FIRST NAME
LAST
DAYTIME PHONE
( )
STREET ADDRESS
CITY
STATE
ZIP CODE
SECTION IV CURRENT MAILING ADDRESS (TO BE COMPLETED BY ALL AGENTS, PERSONAL REPRESENTATIVE,
INVESTIGATORS, EXECUTORS, ETC)
(1) PRINT FIRST NAME MIDDLE LAST DAYTIME PHONE
( )
STREET ADDRESS CITY STATE ZIP CODE
SECTION V NOTICE TO CLAIMANT: INVESTIGATOR OR FINDER FEES
Under Section 1582 of the California Code of Civil Procedures (stated below), an investigator is not allowed to charge a fee of more than 10%
of the recovered amount.
CCP Section 1582 (Restriction on agreement to locate reported property)
No agreement to locate, deliver, recover, or assist in recovery of property reported under Section 1530 may be executed within twelve months of the date
payment or delivery is made to the State Controller. The fee or compensation agreed upon may not exceed 10% of the recoverable property. The agreement
must be in writing and signed by the owner after disclosure in the agreement of the nature and value of the property and the name and address of the person or
entity in possession of the property. Nothing in this section shall be construed to prevent an owner from asserting, at any time, that an agreement to locate
property is based upon excessive or unjust consideration.
CLAIMANTS SIGNATURE:
DATE:
CLAIMANTS SIGNATURE:
DATE:
REPRESENTATIVES SIGNATURE:
DATE:
SECTION VI
PRIVACY NOTIFICATION
The Information Practices Act of 1977 and the Federal Privacy Act require the Unclaimed Property Division to inform you that your Social Security number
and other documents are requested for proper identification and processing of your claim. You have the right to view your records at this office by writing:
Chief, Unclaimed Property Division, P. O. Box 942850, Sacramento, CA 94250-5873
SECTION VII AFFIRMATION
Each of the undersigned claimants affirms that claimant has read the claim and knows the contents thereof, and that claimant is the sole owner of the said
claim and the sole person entitled to receive the money and property set forth in said claim. Each claimant certifies under penalty of perjury that original
instruments such as securities certificates, checks, passbooks, etc., have been submitted or, if unable to produce such said original instruments, certifies that
claimant has not sold, pledged, hypothecated or otherwise transferred said instruments or any interest or right therein. If said instruments are found by
claimant, the claimant agrees to deliver them to the State Controller's Office for cancellation. Each claimant agrees to indemnify and hold harmless the State,
officers and employees from any loss resulting from the payment of said claim.
DO NOT SIGN CLAIM FORM UNLESS A DESCRIPTION OF ACCOUNT IS SHOWN IN SECTION I OR IS ATTACHED TO FORM.
CLAIMANTS SIGNATURE: SSN:
CLAIMANTS SIGNATURE: SSN:
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or validity of that document.
STATE OF CALIFORNIA, COUNTY OF
SUBSCRIBED AND SWORN (OR AFFIRMED) BEFORE ME ON THIS DAY OF , 20 BY
, PROVED TO ME ON THE BASIS OF SATISFACTORY
EVIDENCE TO BE THE PERSON(S) WHO APPEARED BEFORE ME.
SIGNATURE
(SEAL)
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