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                      Unclaimed Property Holder Claim Form 

                                                     Comptroller of Maryland 
   Attach documentation                                                        Division                  Include  an  "Attention"  
                                                    Unclaimed Property
   showing proof of                                                                                      Person in Part A of  
   payment to owner(s)                                         7 St. Paul Street                                     this form  
   for  all  individual  claims                                 Suite 2 3 0 
   exceeding $1,000.00                              Baltimore,  Maryland        2120 2
                                                    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,    Ihereby  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. 0/62024 
UNC PROP 24.01.05/030-03/0902 
                                                          Approved  by: