Fillable STEP 1: Fill out the attached form (Claim (Bay Area FasTrak)

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STEP 1: Fill out the attached form (Claim (Bay Area FasTrak)

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FasTrak
®
Customer Service Center
PO Box 26926
San Francisco, CA 94126
www.bayareafastrak.org
1-877-BAY-TOLL (1-877-229-8655)
Fax 1-415-956-1663
This Form is ONLY for submitting a claim on an uncashed refund check issued by the Bay Area Toll
Authority/FasTrak that has remained unclaimed for more than 3 years and is subject to escheatment to
BATA. This form should NOT be used for other refund claims.
Instructions:
STEP 1: Fill out the attached form (Claim Affirmation Form). When completing the claim forms, please type or print
legibly in blue or black ink. Claims that are illegible will be returned. Claims must be made using the Claim Affirmation
form.
STEP 2: You must sign the Claim Affirmation Form and have it notarized if your claim is over $1,000 or your claim will not
be processed. Please read all of the instructions and make copies of all required documents (driver’s license, etc.).
Owners or heirs are required to provide additional documentation to validate their claims.
STEP 3: Each claimant is required to fill out a separate Claim Affirmation Form for each check.
STEP 4: Please send the completed forms along with all the required documents to the address as shown above and
keep a copy for your records. Please allow eight (8) weeks to receive a new check. The completed forms may be
submitted in person, mail, web or fax.
For additional information or questions, please go to www.bayareafastrak.org/unclaimed_property
or call 1-877-229-8655.
The following is a checklist of the documentation required when sending in your claim:
ORIGINAL OWNER(S) FILING CLAIM
• Completed and signed Claim of Affirmation Form;
• Notarize your Claim of Affirmation Form, if your claim is over $1000;
• Copy of current photo identification for each claimant;
• Proof associating you with the last address known by the RCSC;
• Proof of name change, if different than on the unclaimed property account, such as marriage certificate or court
documents; and
• The original or copy of check, if available.
FILING CLAIM FOR A DECEASED OWNER
• Completed and signed Claim Affirmation Form;
• Notarize your Claim Affirmation Form, if your claim is over $1000;
• Copy of death certificate of the deceased owner(s) of the funds and death certificate of predeceased spouse, if
applicable;
• Copy of current photo identification of claimant;
• The original or copy of check, if available;
• Proof that claimant has the right to file a claim on behalf of deceased; and
• If probate of estate is open and the claimant is claiming by virtue of status as executor or administrator of the estate,
the estate tax identification number and a copy of currently Certified Letters Testamentary, dated within 6 months,
appointing the claimant as executor or administrator of decedent's estate.
BUSINESS CLAIM
• Completed and signed Claim of Affirmation Form;
• Notarize your Claim of Affirmation Form, if your claim is over $1000;
• The original or copy of check, if available,
• Letter of Authorization with the names of officers or officials with authority to sign and claim on behalf of the business;
• Copy of current photo identification officer or official making the claim;
• Business card of the authorized officer or official;
UNCLAIMED PROPERTY CLAIM FORM AND INSTRUCTIONS
• Proof of the business's address that matches the check;
• If your company merged with another company, a copy of the merger agreement; and
• If your company was dissolved, a copy of the articles of dissolution.
CLAIM AFFIRMATION FORM
The undersigned claimant certifies, under penalty of perjury, the claimant has read the claim and knows the contents
thereof and the claimant is the owner/authorized owner of said claim and the person entitled to receive the money set
forth in said claim.
The claimant agrees to indemnify and hold harmless the Bay Area Toll Authority, and its agents, commissioners,
directors, officers, and employees from and against any and all demands, claims, suits or actions arising out of the
payment of said claims.
CURRENT INFORMATION AND SIGNATURE MUST BE PROVIDED FOR EACH CLAIMANT OR YOUR CLAIM WILL NOT BE PROCESSED
Keep a copy for your records.
FasTrak Account Number (or if unknown leave it
blank):
DATE:
Amount of Claim:
$ ________________
First Name or Business Name:
Middle Name:
Last Name:
Day Time Phone Number:
Complete Current Mailing Address:
(Unit/House No./Street/City/State/Zip Code/Country)
Previous Mailing Address(es) Within the Last Seven
(7) Years, If Any:
(Unit/House No./Street/City/State/Zip Code/Country)
Address 1
Address 2
(Fill out this Section if the Claimant Above is NOT the Property Owner)
Property Owner’s First Name or Business Name:
Middle Name
Last Name
CLAIMANT OR AUTHORIZED AGENT SIGNATURE
For claims filed for a business, the authorized owner's signature is required. For claims filed for an estate or trust, the
signature of the executor, administrator or attorney is required.
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02/09/17
NOTE: YOUR SIGNATURE MUST BE NOTARIZED IF THE CLAIM AMOUNT IS $1,000 OR GREATER
State of California
County of ____________________________
Subscribed and sworn to (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)
For Office Use Only
Documents Verified By:
CSR ID: _________
CSR Signature: ________ Date:____________ Finance Initial: ____________ Date: ____________
Approved: _______________ Date: ____________
Rejected: _________________ Date: ____________
Reason:
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STEP 1: Fill out the attached form (Claim (Bay Area FasTrak)

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Completed 21 February 2021

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