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Get Unclaimed Property Reimbursement Form

TAX I.D. NUMBER: CONTACT NAME: TELEPHONE: E-MAIL ADDRESS: DATE REPORTED and REMITTED: TOTAL REPORTED (Amt of Report on UP-1 Form): OWNER S NAME (reported) OWNER S ADDRESS (reported) PROPERTY TYPE CODE PROPERTY ID NUMBER AMOUNT REPORTED DATE OWNER PAID A copy of the canceled check (front and back) or proof the account was reinstated must accompany this request. Comments: Signature: Title Date .

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