Fillable Form also available at NAUPAs Web site www.unclaimed.org: (Nebraska)

Fill Online, Printable, Fillable, Blank Form also available at NAUPAs Web site www.unclaimed.org: (Nebraska) Form

Use Fill to complete blank online NEBRASKA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form also available at NAUPAs Web site www.unclaimed.org: (Nebraska)

On average this form takes 8 minutes to complete

The Form also available at NAUPAs Web site www.unclaimed.org: (Nebraska) form is 1 page long and contains:

  • 1 signature
  • 0 check-boxes
  • 28 other fields

Country of origin: US
File type: PDF

BROWSE NEBRASKA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
State of _____________________ Report Year ______________
PART I HOLDER INFORMATION
Holder Name Address City State Zip
Tax ID# Contact Contact Telephone No.
PART II CLAIM INFORMATION S
Property Code Acct. Reference No. (If Aggregate – Specify) Date Pd. To Owner/Acct. Reactivated * Amount Paid
Owner’s Name (Exactly as on Report) Owner’s Address (As Listed on Report)
Claimant’s Name & Address (If Different than Owner)
*IF AMOUNT WAS REMITTED IN ERROR, ATTACH A
SEPARATE SHEET DETAILING THE ERROR Total Request for Reimbursement: $ ____________
PART III HOLDER CERTIFICATION
I, _________________________________ a duly authorized representative of the holder listed above, do hereby certify
that the above listed funds, or other property which was listed in the Report filed by the holder, have been paid to the
rightful owner(s) or their appointed representative. I agree, upon payment of the above-described property to indemnify
the State and hold it harmless from all claims and loss, demands, costs, and other expenses which the State may sustain
by reason returning property to the holder and by reason further of its refusal to pay the property to any
other person or persons:
Sworn to and subscribed before me this
_____day of __________________, 2020
Notary:_______________________________
My commission expires:_________________
Name and Title of Holder Representative (type or print)____________________________________________
Signature of Holder Representative _______________________________________ Date_______________
Form also available at NAUPA’s Web site www.unclaimed.org
HOLDER REQUEST FOR REIMBURSEMENT
click to sign
signature
click to edit
INSTRUCTIONS FOR HOLDER REQUEST FOR REIMBURSEMENT
A separate Holder Request for Reimbursement should be submitted for each report year and each claimant.
PART I HOLDER INFORMATION: Enter the name, address and Federal Tax ID
number of the Holder, and the name and telephone number of the
Holder’s contact person.
PART II CLAIM INFORMATION: The information provided on this form must be
identical to how the property was originally reported.
S
1) The NAUPA Property Code
2) Account/Reference Number, if any.
3) Date Paid to Claimant or Date Account Reactivated. Evidence of
payment to the rightful owner (or his/her representative) must
be provided.
4) Amount Holder remitted to the State.
5) Owner(s) name and Address as shown on the report.
6) Claimant(s) Name and Address, if different than the owner.
7) Total Reimbursement requested.
PART III HOLDER CERTIFICATION: This notarized statement must be completed
before the State will process the request for reimbursement and make
payment. Proof that the claimant was paid and entitled to the property must be
maintained and is subject to audit and review by the State.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form also available at NAUPAs Web site www.unclaimed.org: (Nebraska)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 20 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document