Unclaimed Monies SECTION 1) CLAIMANT INFORMATION OF PROPERTY CLAIMED Individuals: 1) A copy of current photo identification for each claimant 2) Verification of address, if mailing address is different from the original mailing address or photo identification 3) Death Certificate (if making claim for deceased original owner) Businesses: 1) Copy of current photo identification for the authorized agent signing the form 2) Letter of Authorization on Company letterhead with the names of officers or officials with authority to sign and claim on behalf of the business 3) If your company merged with another company, a copy of the merger agreement 4) If your company was dissolved, a copy of the articles of dissolution Payee Full Name / Business Name (required) Upload Valid Government ID (required) Street Address (required) City (required) State (required) Zip Code (required) Country (required) Contact Phone Number (required) Email Address (required) Amount of Claim (required) SECTION 2) CLAIMANT SECTION CHECK NEVER RECEIVED – (Complete Section III) That Claimant did not receive and did not cause said check to be presented for payment or otherwise received the proceeds of said check. CHECK RECEIVED AND LOST OR DESTROYED – (Complete Section III) That Claimant received the check and has not caused said check to be presented for payment or otherwise received the proceeds of said check, as the check has been lost or destroyed. The Claimant requests that a new check be issued in the amount shown in Section I, by JBWD in consideration for which the Claimant hereby agrees to indemnify JBWD, its officers, agents, and employees from any and all expense, loss, or liability whatsoever which may arise out of or be in any way connected with the issuance of said check. It is further agreed that in consideration of the issuance of said replacement check, if said check is found, Claimant will forward it to the Finance Department immediately or be held responsible for payment if the original check is presented for payment. Claimant Statement (Grounds for Claim) (required) Check Never Received Check Received and Lost or Destroyed SECTION 3) CLAIMANT AFFIRMATION Mail check to (addresses): Mail check name: (required) Mail check address: (required) Mail check city: (required) Mail check state: (required) Mail check zip code: (required) I certify under the penalty of perjury that I am the lawful payee of the aforementioned check or an authorized representative of the payee, and, that the foregoing declaration is true and correct. (required)True and Correct Your Signature (required) Confirm e-Signature Review Electronic Records and Signatures Policy (required)Read our Electronic Record and Signature Disclosure I agree to use electronic records and signatures There was a problem saving your submission. Please try again later. Please wait while your submission is being saved... Submitting...Submit Thank you, your submission has been received.
