Unclaimed Funds Form – East Fork Special Utility District

Submit a copy of ONE of the following pieces of documentation with this signed and completed claim form:

Your driver’s license
W-2 form
Federal Tax ID number (if the cash is owned by a commercial entity)
Any official form commonly used for identification.

Upload 1 Above Listed Item *

Click or drag a file to this area to upload.

Do not upload any form of identification that includes a social security number.

List the address associated with the cash being claimed *

Address Line 1

Address Line 2

City

State

Zip Code

Claimants are required to provide East Fork with sufficient proof and documentation to substantiate entitlement to payment. You must be eighteen (18) years or older to claim property. Claimant Information:

Name *

First

Last

Email *

Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

Driver's License Number *

Phone *

The named Claimant hereby certifies that this claim for cash presumed abandoned is valid and just, that all statements herein are true and correct, and that upon payment of this claim said Claimant will indemnify and hold harmless the East Fork Special Utility District, its officers and employees, from any damages, claims or losses of any kind resulting from the payment of the above described claim to Claimant.

Signature *

Type Your Name Above. This Is Your Signature Affirming the Above Changes.