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Unclaimed Property Holder Claim Form
Comptroller of Maryland
Attach documentation Unclaimed Property Division Include an "Attention"
showing proof of Person in Part A of
payment to owner(s) 7 St. Paul Street this form
for all individual claims Suite 320
exceeding $1,000.00 Baltimore, Maryland 21202
410-767-1700 or 1-800-782-7383
TDD 410-767-1967
Part A - Holder Information
Name of Holder Attn: FEIN Number
Mailing Address Telephone number
City, State, Zip code
Part B - Information on property claimed
Name of Owner Holders Account Original Report Amount or
Number Date Description of
Property Claimed
Part C - Affidavit
Under penalties of perjury, I hereby certify that the foregoing information is true and correct. I further certify that the
property claimed has been or will be returned or credited to the lawful owner or owners. I am authorized to represent that
the holder will indemnify the State of Maryland, its officers and employees for any loss or claim whatsoever arising from
the payment of this claim.
X
Signature Title Date
Part D - For office use only
Claim No.: Control No.: Holder No.: Report Year:
Rec'd.: Total: $
COT/ST 917 Rev. 06/2024
UNC PROP 24.01.05/030-03/0902
Approved by:
