Indiana Claim Form

Indiana Claim Form

INSTRUCTIONS FOR ITEMS NEEDED TO PROCESS YOUR CLAIM 

***CLAIMS SUBMITTED WITHOUT SUPPORTING DOCUMENTATION WILL BE RETURNED TO SENDER WITHOUT REVIEW *** 

I. Completed and signed claim form 

II. Required documentation – proof of ownership (Copies only. Originals will not be returned.)

 

FOR OWNERS OF PROPERTY

Claimants driver’s license or other picture identification

A document stating the claimants social security number

Copy of document connecting you to the Reporting Company (i.e. copy of stock certificate, bank statement, dividend statement, insurance card) OR

A copy of something showing the reported address, if given (i.e. old utility bill, W-2 forms, old bank checks titles, or similar information)

For Guardian, Trustee, or Power of Attorney provide a certified copy of appointment

Documentation showing name change, if applicable

 

FOR HEIRS TO THE OWNER OF PROPERTY

Open Estates

Copy of the owner’s death certificate.

Copy of the Letter of Testamentary.

Federal ID # for Estate.

Documentation showing the Social Security Number of the Deceased.

Copy of a document that connects the Deceased to the Reporting Company OR to the reported address, if given

Closed Estates

Copy of the owner’s Death Certificate.

Documentation showing the Social Security number of the Deceased.

Copy of a document that connects the Deceased to the Reporting Company OR to the reported address, if given.

Copy of “Letters of Testamentary” or “Letters of Administration” and a notarized affidavit signed by the executor or administrator to collect and distribute the funds to the entitled heirs. OR

Copy of the “Final Report of Distribution” or the “Closing Statement”. All heirs must sign claim form; provide picture identification showing their current address and copy of documentation showing their social security number (add additional pages if necessary).

No “Will” and /or No “Probate Proceedings”.

Small Estates Affidavit (if Deceased’s total assets are under $25,000).

Copy of the owners Death Certificate.

Copy of decedents’ obituary (if available).

Documentation showing the Social Security number of the Deceased.

Copy of a document that connects the Deceased to the Reporting Company OR to the reported address.

All Heirs must sign the Claim Form, provide picture identification showing their current address and copy of documentation showing their social security number (add additional pages if necessary).

 

FOR A COMPANY WHO IS THE OWNER OF PROPERTY

Notarized affidavit on company letterhead signed by a current officer of the corporation (as registered with the Indiana Secretary of State’s Office) authorizing the agent to sign on behalf of the company to collect the funds.

Documentation showing the Federal Identification Number (FEIN)

Documentation that connects the Company to the reported address, if given

ALL CLAIMS SUBJECT TO VERIFICATION OF PROPER DOCUMENTATION TO PROVE THAT YOU ARE THE RIGHTFUL OWNER OR HEIR.

Mailing Information

 

Name:

  

Address:

  

City:

  

State:

 

 

Zip:

  

Claimant Information (if different)

 

Claimant:

  

Co-Claimant:

  

Address:

  

City:

  

State:

 

 

Zip:

  

Claimant SSN/FEIN:

  

Co-Claimant SSN/FEIN:

  

Daytime Phone

  

Claimant Birth Date:

  

Co-Claimant Birth Date:

  

Relationship to Original Owner:

  

Owner/Property Information

 

 

 

Property ID:

 

 

Reporting Company:

 

 

Number of Shares:

 

 

Amount:

 

 

Name:

 

 

Address:

 

 
 

 

 
 

 

 

 

 

Documentation

 

You must provide documentation to support your claim. Please refer to the instructions on the left side of the screen.

 

Affidavit

 

Under penalties of perjury, I/We certify that the information provided 
on this claim form is true, and all supporting documentation presented 
are either original or true, unaltered copies of the original documents.
Upon payment of this claim, said claimant will indemnify and hold 
harmless the State of Indiana, Officers and Employees from any damages,
claims or losses of any kind resulting from payment of the above described
property.
 
CLAIMANT SIGNATURE
Printed Name 


Signature______________________________________Date______________

CO-CLAIMANT SIGNATURE
Printed Name 


Signature______________________________________Date_______________

 

Please return completed form to:

 

Indiana Unclaimed Property Division
302 West Washington Street, 5th Floor
Indianapolis, IN 46204

Please allow adequate time for processing.