Guidelines for

Claiming
Unclaimed Property

Malia M. Cohen
California State Controller

January 2022
 Contents
Claims Process...................................................................................................................... 1

Internet ................................................................................................................ 1

Telephone ........................................................................................................... 1

Mail..................................................................................................................... 2

No Evidence of Account..................................................................................... 2

Required Documentation..................................................................................................... 3

Identification....................................................................................................... 3

Documentation by Property Type....................................................................... 3

Savings or Checking Accounts ................................................................ 3

Stocks, Dividends, Bonds or Debentures ................................................. 4

Life Insurance Accounts .......................................................................... 4

Escrow Accounts...................................................................................... 5

Negotiable Instruments, Certified Checks, Money Orders, or

Travelers Checks ...................................................................................... 5
Safe Deposit Box Contents ...................................................................... 5

Business Accounts ................................................................................... 6

Corporation/Business Entity/Partnership ................................................. 6

Governmental Agency Accounts ............................................................. 6

Miscellaneous Accounts........................................................................... 7

Deceased Owners ............................................................................................... 7

Multiple Owners ................................................................................................. 7

 Incomplete Claim Package ................................................................................. 7

Claim Consideration ............................................................................................................ 8

Right to Claim Property From Holder ................................................................ 8

Report of Interest Income ................................................................................................... 9

Asset Recovery Agreements ................................................................................................ 10

Appendices

Face Sheet (UFS-1) .................................................................................................. A-1

Claim Form............................................................................................................... A-2

Declaration Under Probate Code Section 13101 ...................................................... A-3

Table of Heirship ...................................................................................................... A-4

Holder’s Claim For Reimbursement......................................................................... A-5

 Claims Process

Claims Process
A claim for unclaimed property can be initiated through the Internet, by
telephone, or by mail. The State Controller’s Office updates the unclaimed
property records monthly, and account information can be accessed at any
time. Instructions for filing a claim are described in this guide.

Internet The State Controller’s Office has developed an unclaimed property database
that provides convenient, 24-hour access to individual or business accounts.
Search parameters include name(s) and last known city. If an account is located,
a claim form and instructions for filing a claim can be generated immediately.

The Internet database does not contain all unclaimed property accounts. The
State Controller’s Office receives reports throughout the year and accounts
are posted to the Internet periodically. If you feel you may have other
accounts that did not appear in your search, return to this site at a later date.

The database and search instructions can be accessed on the State

Controller’s web site, at http://www.sco.ca.gov. Click on “Unclaimed
Property.”

To access the unclaimed property database by telephone, contact the State

Telephone Controller’s Customer Service Unit. California residents can call toll-free, at
800-992-4647 between the hours of 8:00 AM and 5:00 PM, Monday through
Friday (except holidays). Those outside California may call (916) 323-2827.
The customer service representative (CSR) will request the name to be
researched and the applicable social security number, if available.

In order to locate all funds that a claimant may be owed, the CSR may ask
for additional information concerning prior addresses. This information will
help locate funds in the event that there are similar names on the database.
The CSR generally conducts the search while the caller is on the line. If an
account is located, a claim form and instructions for filing the claim are sent
to the claimant. In some cases, additional documentation may be requested after
initial proof of entitlement is submitted.

Malia M. Cohen · California State Controller 1

 Claims Process

Mail Requests for searches for unclaimed property may also be submitted in writing.
To ensure that the requested name is researched thoroughly, the claimant’s
social security number and all addresses of residence must be provided. The
request should be sent to:

State Controller’s Office

Unclaimed Property Division
P.O. Box 942850
Sacramento, CA 94250-5873

When a written request for a search is received, the claimant is sent notification
in writing of whether or not the search located an account.

No Evidence of It is possible that unclaimed property was remitted to the State Controller’s
Office but does not appear on the database. This occurs if the account was
Account submitted on electronic media that was incompatible with the unclaimed
property computer system or if the report is in transit.

If a claimant has been notified by a business or financial institution that

property was remitted to the State Controller but it does not appear on the
database, the State Controller will return the claim unpaid. This does not
constitute a denial of the claim. The claimant should contact the business or
financial institution that reported the property (the holder). The claimant should
ask the holder to provide the date the property was reported and a copy of
the report face sheet (see Appendix A-1). If this information can be obtained,
it should be sent to the State Controller along with the original claim and
supporting data for further research. (Note that the holder is not required to
retain such records after seven years.) If no additional information
can be obtained to assist the State Controller in locating the account, the
claimant should visit the State Controller’s website at www.sco.ca.gov or call
the toll free number at a later date, as accounts are continually loaded to the
database.

A holder may pay the unclaimed property directly to the claimant and then be
reimbursed by the State Controller once the holder’s report is corrected and
loads to the computer system.

Malia M. Cohen · California State Controller 2

Guidelines for Claiming Unclaimed Property

Required Documentation
Identification To ensure that the rightful owner or heir is paid, the State Controller requires
sufficient identification before a payment is authorized. The following three
items must be provided:

 State Controller’s Claim Form ( see Appendix A-2);

 Copy of a driver’s license, a Department of Motor Vehicles

identification card, or a passport; and

 Documentation verifying the claimant’s social security number or

federal tax identification number or (if open estate) federal tax
identification number.

If the owner is deceased, one or more of the following documents must be

provided for identification in addition to the three listed above:

 Birth certificate of account owner and heir(s);

 Death certificate of account owner and heir(s); and/or

 Marriage certificate of account owner and heir(s), if applicable.

Documentation by In addition to the above requirements, the following documentation, as well

as other documents which may be required to substantiate the claim, must be
Property Type submitted according to the type of unclaimed property.

Savings or Checking Accounts

Required documentation:

 Account statement;

 Bank passbook; or

 Correspondence listing account numbers.

If the passbook or account statement is unavailable, claimants are required to

show proof of residence at the address shown on the account as reported to
the State Controller.

Malia M. Cohen · California State Controller 3

Guidelines for Claiming Unclaimed Property

Stock, Dividends, Bonds or Debentures

Required documentation:

 Original stock certificate;

 Original dividend check;

 Original bond;

 Original debenture; or

 Account statement.

If the original certificate is not available, the State Controller may allow
payment based upon other documentation submitted by the claimant, such as
verification of occupancy at the registered address, proof of purchase, or
cashing or evidence of a dividend check. If warranted, the State Controller
may require a lost instrument bond from the claimant.

Note: Submission of a lost instrument bond only is not considered sufficient

proof of ownership.

California’s Unclaimed Property Law requires the State Controller to sell

securities within two years of delivery to the State Controller’s Office. If a
claimant’s securities have been sold, the claimant will receive the market value
of the securities received at the time of sale. The law does not provide for
interest to be paid on any claims.

Note: The State Controller’s Office is not authorized to buy back the claimant’s
shares nor will it make up the difference in sale proceeds in the event the stock
was sold below current market value. The State Controller is required to sell
stock within the statutory period of two years (Code of Civil Procedure Section
1563).

Life Insurance Accounts

Required documentation:

 Insurance policy; or

 Insurance statement.

If the items above are not available, claimants are required to show proof of
residence or occupancy at the address shown on the account as reported to
the State Controller.

Malia M. Cohen · California State Controller 4

Guidelines for Claiming Unclaimed Property

Escrow Accounts

The Buyer’s/Seller’s closing statement is required documentation.

If the statement is not available, the claimant is required to show proof of

residence or occupancy at the address shown on the account as reported to
the State Controller.

If the account shows both buyer and seller, the escrow agreement must be
provided in order to identify the proper owner.

Negotiable Instruments, Certified Checks, Money Orders, or

Travelers Checks

Required documentation: the original negotiable instrument.

If the original instrument is unavailable, additional documentation is needed

to verify claims for negotiable instruments. You will be required to
provide other available documentation along with a Declaration of Loss
form. Please contact the Unclaimed Property Division by telephone at (916)
323-2827 for further instructions. Also, if you are filing a claim and know
there are multiple owners on the account, please note that each owner/
claimant must sign the claim form and submit the required documentation.

Safe Deposit Box Contents

Required documentation:

 Account statement; or

 Safe deposit box key.

If the items above are not available, proof of residence or occupancy at the
address shown on the account is required. If proof of residence is not
available or if the reporting agency did not report an account owner’s last
known address, evidence must be submitted proving an association with the
reporting agency.

California’s Unclaimed Property Law requires the State Controller to sell the
contents of safe deposit boxes if the contents appear to have monetary value;
all other safe deposit box contents (e.g., wills, statements, letters, deeds) are
destroyed. Proceeds from the sale are used to satisfy any bank liens. Remaining
proceeds are credited to the owner’s account until a claim is presented. The
law does not provide for interest to be paid on any claims. In the event that the
contents of a safe deposit box are not sold and a claim is presented, the State
Controller, upon proof of ownership, will return the property by
insured/registered mail after the claimant pays any liens on the safe deposit
box. The payment for the lien is made to the State Controller, which forwards
it to the bank.

Malia M. Cohen · California State Controller 5

Guidelines for Claiming Unclaimed Property

Business Accounts

Business accounts such as vendor checks, accounts receivable credit

balances, or rebates can be claimed by providing:

 Account statement verifying the relationship between the claimant and

the company;

 Credit memo; or

 Other correspondence or documentation supporting the claim.

Corporation/Business Entity/Partnership

Business accounts such as vendor checks, accounts receivable credit

balances, or rebates can be claimed by providing:

 Evidence that the corporation is in good standing with the Secretary of

State’s Office (a statement of corporate standing can be obtained from
the Business Programs Division, Business Filing Section, Secretary of
State’s Office, 1500 Eleventh Street, Sacramento, CA 95814); and

 Tax return; and

 Letterhead or a business card for an authorized officer of the agency, and

if dissolved or merged, evidence of all mergers, which may include
partnership agreements, copies of merger/articles of incorporation, and
dissolution and wind-up documents; and

 Final tax return showing assets were distributed.

If the items above are not available, claimants are required to show proof of
residence or occupancy at the address shown on the account as reported to
the State Controller. Other documents may be required to establish proof of
ownership.
Governmental Agency Accounts

Business accounts such as vendor checks or accounts receivable credit

balances can be claimed by providing:

 Letterhead or a business card for an authorized officer of the agency.

 Copy of document verifying Federal Tax Identification number.

Other documents may be required if the account is in the name of more
than one owner.

Malia M. Cohen · California State Controller 6

Guidelines for Claiming Unclaimed Property

Miscellaneous Accounts

Other types of accounts can be claimed by providing documentation

associating the owner with the account. If proof of residence/occupancy or
last known address is not available, documentation associating the claimant
with the reporting agency must be submitted.

Deceased Owners If the owner of the account is deceased and an heir or administrator of the
estate is claiming the property, the State Controller requires the claimant to
provide the death certificate for the deceased owner, plus one of the
following documents or groups of documents:

• Copies of currently certified letters, dated within 6 months,

appointing the executor or administrator of the decedent’s estate and
assigning the estate tax identification number;

• Copy of the court-ordered distribution of the decedent’s estate;

• If the estate was valued at less than $150,000 and was not probated
or distributed by the courts, a copy of the decedent’s will and/or trust
agreement, along with a completed Declaration Under Probate Code
Section 13101 form (see Appendix A-3). If the decedent died on or
between January 1, 2020, and March 31, 2022, this amount increases to
$166,250;

• Table of Heirship form (see Appendix A-4); or

• If the estate or owner’s account was valued at more than $150,000, a

copy of the final decree of distribution. ). If the decedent died on or
between January 1, 2020, and March 31, 2022, this amount increases to
$166,250; or

• Community property confirmation order under Probate Code Section

13656; or

• Trustee certificate under Probate Code Section 18100.5.

If the certified letter, court-ordered distribution, or decedent’s will is not

available, the claimant may be required to complete a certification of non-
probate and submit a declaration form, along with a Table of Heirship form
indicating the lines of succession (see Appendices A-3 and A-4).

Multiple Owners If there are three or more owners on an account, the State Controller requires
the signatures of all owners. Since the claim form has only two signature
blocks, make a copy of the Claim Form/Affirmation section (see back of
Appendix A-2). Submit this additional section with the claim and appropriate
documentation.
Incomplete Claim The State Controller will return any claim package that does not contain
Package documentation adequate to prove ownership. The file may be resubmitted by
the claimant when the necessary supporting documentation has been
obtained.
Malia M. Cohen · California State Controller 7
Guidelines for Claiming Unclaimed Property

Claim Consideration
The State Controller’s Office will consider a claim within one hundred
eighty (180) days of receipt. If the claim is denied in whole or in part, the
claimant will be provided with a written notification of the denial.

Right to Claim If a claimant is unable to prove a claim with the State Controller, the
Property From claimant can attempt to substantiate the claim with the institution that turned
over the account (the holder). If the holder pays the claimant, the holder will
Holder be reimbursed by the State Controller for the exact amount that was paid to
the claimant by filing a Holder’s Claim For Reimbursement form (see
Appendix A-5).

Malia M. Cohen · California State Controller 8

Guidelines for Claiming Unclaimed Property

Report of Interest Income

Beginning in August of 2003, the Unclaimed Property Law no longer
provides for interest to be paid on any claims. However, for claims paid
prior to the change in the law, the State Controller is required to issue a 1099
statement indicating the amount of interest paid to an owner of the unclaimed
property.

The 1099 statement is filed with the Internal Revenue Service and the
California Franchise Tax Board. The State Controller’s Office issues 1099
statements once a year, during the month of January. This statement reports the
amount of interest that the State Controller paid to a claimant in the tax year
that the unclaimed property account was paid. Questions related to this
document may be directed to the California State Controller’s Office, P. O. Box
942850, Sacramento, CA 94250, or can be asked of a tax preparer. When
filing state and federal income tax returns, this income must be reported.

If the holder pays a claimant and is reimbursed by the State Controller, the
holder is responsible for issuing the 1099 statement.

Malia M. Cohen · California State Controller 9

Guidelines for Claiming Unclaimed Property

Asset Recovery Agreements

Asset recovery agreements submitted by organizations, private investigators,
attorneys, heir finders, and other individuals or entities are required to be in
compliance with Code of Civil Procedures Section 1582. Section 1582 provides
as follows:

No agreement to locate, deliver, recover, or assist in the recovery of property

reported under Section 1530, entered into between the date a report is filed
under subdivision (d) of Section 1530 and the date of publication of notice
under Section 1531 is valid. Such an agreement made after publication of
notice is valid if the fee or compensation agreed upon is not in excess of 10
percent of the recoverable property and the agreement is in writing and
signed by the owner after disclosure in the agreement of the nature and value
of the property and the name and address of the person or entity in
possession of the property. Nothing in this section shall be construed to prevent
an owner from asserting, at any time, that any agreement to locate property is
based upon an excessive or unjust consideration.

Notwithstanding any other provision of law, records of the Controller's office

pertaining to unclaimed property are not available for public inspection or
copying until after publication of notice of the property or, if publication of
notice of the property is not required, until one year after delivery of the
property to the Controller.

If the State Controller’s Office determines that a submitted asset recovery

agreement does not comply with Civil Code of Procedures Section 1582, it will
not process claims filed under that agreement.

Malia M. Cohen · California State Controller 10

Guidelines for Claiming Unclaimed Property

Appendices

Malia M. Cohen · California State Controller

California State Controller’s Office
UNIVERSAL HOLDER FACE SHEET (must be completed and attached with all reports)
UFS-1(Rev. 04/09)
Mail to: California State Controller’s Office, Malia M. Cohen, State Controller, Unclaimed Property Division, P.O. Box 942850, Sacramento, CA
94250
Notice Report Or Remit Report
… Due Before November 1 or … Due Between June 1 and June 15 or
… Life Insurance Due Before May 1 … Life Insurance Due Between December 1 and December 15

Section A—Holder Information

FEIN Branch Number Report As of Date Check Number / EFT Debit Ref Number (Remit Report Only)

Section B—Report Completion Contact Holder Name

Street Address

P.O. Box Number City State Zip Code Country

Contact Name (For report completion) Title Phone Number Extension

E-mail Address (Optional)

Section C—Property Owner Contact Holder Name

Street Address

P.O. Box Number City State Zip Code Country

Contact Name Title Phone Number Extension

E-mail Address (Optional)

Section D—Holder Agent Contact (If Applicable) Agent Name

Street Address

P.O. Box Number City State Zip Code Country

Contact Name (For report completion) Title Phone Number Extension

E-mail Address (Optional)

Section E—Prior Holder Name If you are the successor to a previous holder of property, or if you have changed your name, please list such prior name
Name

Total Reported/Remitted Dollars Total Reported/Remitted Shares Includes Safe Deposit Box
Section F—Holder Report Totals … Yes … No
*Any Remittance of $20,000.00 or more must be paid by Electronic Funds Transfer (EFT), pursuant to CCP Section 1532*
Section G - Holder Business Information
Organization Type: NAISC Code:
Incorporation State: Charter Federal … or State …
Incorporation Date: / / Charter Date:

Section H– Demutualization Proceeds …This report includes proceeds from the demutualization of an insurance company for the category checked below.
Date of Demutualization
… Distribution not sent, because holder did not have a valid address (CCP Section 1515.5 (a)). Abandoned Immediately
… Distribution sent but returned by the post office as undeliverable (CCP section 1515.5 (b)). Abandonded after two years
… Distribution sent and not returned by the post office (CCP Section 1515.5 (c)). Abandonded after three years

Section I: Verification
Section I- Verification If made by an individual, shall be verified by the individual; if made by a partnership, by a partner; if made by an unincorporated association or
private corporation, by an officer; if made by a public corporation, by its chief fiscal officer or other employee authorized by the holder (CCP Section 1530(e)).

The undersigned, declares, under penalty of perjury, that, to the best of (his) (her) knowledge and belief, the following sheets
contain a full, true, and complete report of unclaimed property which is presumed unclaimed under the provisions of Part 3, Title 10, Chapter 7, Code of Civil Procedure,
commencing with Section 1500, and Title 2, California Administrative Code, Sections 1150 et seq. The Undersigned also confirms that all properties not listed on the
Remit Report, which were initially included on the Notice Report, were due to contact by the apparent owner, or the property being reactivated or returned to the
rightful owner. Properties not included on the Notice Report cannot be listed on the Remit Report and must be reported on a Supplemental Notice Report.

Signature Title Date

UFS-1 (Rev 04/09)

 Malia M. Cohen
California State Controller

This is to inform you that, according to our records, you may be entitled to the money, property or the
proceeds from any sale of the property listed below.

The California State Controller’s Office has a program to return unclaimed property value to rightful
owners or heirs. Unclaimed property turned over to the State, primarily consists of money, securities, or
tangible property held by businesses or financial institutions for more than three years without owner
contact. California law requires businesses to transfer such property to the state at the close of the
dormancy period.

You may claim this property or the proceeds thereof by completing and signing the reverse side of this
form. In addition, you must provide a copy of your driver’s license that shows your current address and
some form of verification of your social security number, such as a copy of your social security card or a
tax return showing your name and social security number. If you do not have all of the items required,
please send as much information as possible to prove this claim. If you are an heir, not a direct owner,
provide a certified copy of the owner’s Death Certificate and Will or a Final Decree of Distribution. Send
these documents to:

Once your signed claim form and required documentation have been received, please allow up to 180
days for processing. For more information regarding this program, including filing instructions and
forms, or to inquire about your claim status, visit the State Controller’s website at www.sco.ca.gov

PLEASE NOTE: Properties recently remitted to the State Controller’s Office may not appear on
our website. If you have any questions or want to confirm we have your property, please call the
Unclaimed Property Division at (800) 992-4647. Out of state callers may call (916) 323-2827.

Type of Property:

Amount Reported:
Reported By:

Owner’s Name:
Reported Address:

Reference:

A-2
 CLAIM FORM / AFFIRMATION

Each of the undersigned claimants certifies under penalty of perjury: That claimant has read the claim and knows the contents thereof;
that claimant is the owner of the said claim and the person entitled to receive the money and property set forth in said claim.

Each claimant agrees to indemnify and hold harmless the State, its officers and employees from any loss resulting from the payment of said
claim. EACH CLAIMANT MUST SIGN THIS AFFIRMATION OR THE CLAIM WILL BE RETURNED.

LAST NAME OR BUSINESS NAME FIRST NAME MIDDLE INIT. SSN OR FEDERAL TAX ID

CURRENT MAILING ADDRESS CITY

STATE / PROVINCE ZIP COUNTRY DRIVER’S LICENSE NO.

DAYTIME PHONE SIGNATURE DATE

LAST NAME OR BUSINESS NAME FIRST NAME MIDDLE INIT. SSN OR FEDERAL TAX ID

CURRENT MAILING ADDRESS CITY

STATE / PROVINCE ZIP COUNTRY DRIVER’S LICENSE NO.

DAYTIME PHONE SIGNATURE DATE

YOUR SIGNATURE(S) MUST BE NOTARIZED IF THE CLAIM AMOUNT IS $1,000 OR GREATER

ALL CLAIMS FOR SECURITIES OR SAFE DEPOSIT BOXES MUST BE NOTARIZED

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)

PRIVACY NOTIFICATION

The Information Practices Act of 1977 and the Federal Privacy Act require this Bureau to inform you that your Social Security number and
other documents are requested for property identification and processing of your claim.

You have the right to view your records at this office by writing: Chief, Unclaimed Property Division, P.O. Box 942850,
Sacramento, CA 94250-5873

FOR CALIFORNIA STATE CONTROLLER’S OFFICE USE ONLY

ANALYST SUPERVISOR/MANAGER ADMINISTRATION
PREPARED BY DATE APPROVED BY DATE APPROVED BY DATE

REVIEWED BY DATE APPROVED BY DATE APPROVED BY DATE

DOC 1 2 3 4 5 6 7 8 9 10 11 12
Rev 01/08
 Declaration Under Probate Code Section 13101
The undersigned, each for himself or herself and not for the others, declare:

1. That [Name of Decedent], hereinafter “Decedent,” died in the

City of , County of ,
State of on , 20 .

2. At least 40 days have elapsed since the death of Decedent, as shown in a certified copy of the Decedent’s death certificate
attached to this declaration.

3. Check one of the following appropriate boxes.

No proceeding is now being or has been conducted in California for administration of the Decedent’s estate.
The decedent’s personal representative has consented in writing to the payment, transfer, or delivery to the
affiant or declarant of the property described in the affidavit or declaration.

4. The current gross fair market value of the decedent’s real and personal property in California, excluding the property
described in section 13050 of the California Probate Code, does not exceed $___________. (See instructions under
Section 4 for amount.)

5. The unclaimed property identification (PID) number(s) of the Decedent which is/are to be paid, transferred or delivered by
the California State Controller’s Office to the declarant pursuant to this declaration is identified below. Attach a list of the
PIDs if extra space is required.

6. Check one of the following appropriate boxes, and, if applicable, fill in the blank.
The declarant(s) is/are the successor(s) of the Decedent (as defined in Section 13006 of the California Probate
Code) to the Decedent’s interest in the described property.
The declarant(s) is/are authorized under Section 13051 of the California Probate Code to act on behalf of
the successor of the Decedent (as defined in Section 13006 of the California Probate Code) with respect to
the Decedent’s interest in the described property.
The name of the successor of the Decedent is:

7. No other person has a superior right to the interest of the Decedent in the described property.

8. The declarants request that the described property be paid, delivered, or transferred to the declarants.

9. I declare under penalty of perjury, under the laws of the State of California, that all statements contained in this form and
any accompanying documents are true and correct, with full knowledge that all statements are subject to investigation and
that any false or dishonest statement may be grounds for denial of the claim submitted.

Signature Name [Print or Type] Date:

Signature Name [Print or Type] Date:

Signature Name [Print or Type] Date:

Rev. 1/2020 A-3

Please note: This form must be completed in full and notarized. Property ID #
Table of Heirship for , Deceased
Date of Death:
Date of
FIRST MIDDLE (MAIDEN) LAST Birth Death
3rd
1. Spouse of the Deceased 2nd
1st
1st
2nd

2. Children of the 3rd

4th
Deceased
5th
6th
1st
3. Grandchildren of the 2nd
Deceased 3rd
4th
5th
4. Parents of the Father:
Deceased Mother:
1st
5. Brothers and Sisters 2nd
3rd
of the Deceased
4th
5th
1st
6. Children of the 2nd
3rd
Deceased Brothers and
4th
Sisters 5th
The undersigned claimant, being duly sworn, certifies under perjury that the above information is true and correct to
the best of his or her knowledge, and that said claimant has full authority to act on behalf of the other claimants for
the purpose of completing the above information.

PLEASE PRINT FULL NAME SIGNATURE

STREET ADDRESS CITY STATE ZIP DAYTIME TELEPHONE NUMBER

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)

A-4
 HOLDER’S CLAIM FOR REIMBURSEMENT FOR SCO USE ONLY
C/A#
MAIL TO: Malia M. Cohen REMIT DATE:
CALIFORNIA STATE CONTROLLER AMOUNT $
UNCLAIMED PROPERTY DIVISION RESEARCHER:
P.O. BOX 942850 DATE:
SACRAMENTO, CA 94250-5873

Note: Requirements and Instructions on Page 2

REPORT DATE:
(DATE SHOWN ON THE ATTACHED UFS-1 FORM)

REPORTED TOTALS: Dollars: Shares:

OWNER’S NAME: STREET
ADDRESS: CITY,
STATE, ZIP CODE:

OWNER ACCOUNT NUMBER/IDENTIFICATION (SSN):

OWNER PROPERTY REPORTED AMOUNT: Dollars: Shares:

ACCOUNT TYPE: (Circle one) Savings Checking Cashier’s Check Money Order Other
If Negotiable Instrument, Enter Check Number:
REIMBURSEMENT CLAIMED $ Securities (# of shares)

HOLDER’S USE ONLY

Warrants are paid to the holder shown below:

Holder’s Name: Street

Address: City,
State, Zip Code:
Holder’s Federal Identification Number (FEIN):

Authorized Agent (If Applicable):

Name: Title:
Phone number:
E-mail address:

Reason for claimed reimbursement:

NOTE: A SEPARATE FORM IS REQUIRED FOR EACH ACCOUNT FOR WHICH REIMBURSEMENT IS CLAIMED

AFFIRMATION AND SIGNATURE

I hereby affirm, under penalty of perjury, that I am an authorized agent of the holder named in this Holder’s Claim for Reimbursement
and duly authorized to make said claim upon the State Controller's Office, as evidenced by the Letter of Authorization accompanying
this claim. The above-named holder hereby agrees to indemnify and hold harmless the State, its officers and employees from any loss
as a result of payment of the amount claimed.

Signature: Date:

YOUR SIGNATURE(S) MUST BE NOTARIZED IF THE CLAIM AMOUNT IS $1,000 OR GREATER

ALL CLAIMS FOR SECURITIES OR SAFE DEPOSIT BOXES MUST BE NOTARIZED

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)

HCR-1 Revision 09/08 A-5

 State Controller's Office
Unclaimed Property Division
P.O. Box 942850
Sacramento, California 94250-5873
(916) 464-6284

http://www.sco.ca.gov