STATE OF SOUTH CAROLINA UNCLAIMED PROPERTY PROGRAM
STATE OF SOUTH CAROLINA UNCLAIMED PROPERTY PROGRAM
HOLDER'S CLAIM FOR REIMBURSEMENT
Section 27-18-210 (B) of the South Carolina Code of Laws allows a holder who has reported and remitted an account to the State Treasurer as unclaimed to make payment to the owner and then to seek reimbursement from the State Treasurer for that payment. Before paying the rightful owner, we urge you to call the Unclaimed Property Program Office at (803) 737-4771 to verify the funds have not already been claimed.
To request a reimbursement, return this form, with evidence the owner has been paid (e.g., copy of the check issued, verification of an account being re-established), to the State Treasurers Office Unclaimed Property Program, P. O. Box 11778, Columbia, SC 29211. Normal processing time for a holder reimbursement is 4-6 weeks.
HOLDER INFORMATION
Holder Name___________________________________________________________________________________
Mailing Address_________________________________________________________________________________
City _______________________________________________ State _____________ Zip _____________________
Attn: ____________________________________________________ Phone number ________________________
Federal Tax Identification number _____________________________Fax number __________________________
OWNER ACCOUNT INFORMATION If you are requesting reimbursement for a single account/owner, complete the information listed below. If you are requesting reimbursement for multiple accounts/owners, you may attach a list of all owners to a single form. Please note: If your company files under multiple FEINs, reimbursements for each FEIN should be submitted separately.
Owner's Name (As Reported)
Owner's Address (As Reported)
Year Reported
Amount Reported for Owner
The undersigned states, under penalty of perjury, that a payment of $_________ was made by the undersigned holder to the owner(s) listed above/attached who was (were) rightfully entitled to this money and that a claim for reimbursement is hereby made pursuant to the provisions of the laws of South Carolina.
Upon receipt of payment of this reimbursement, the undersigned holder agrees to indemnify and hold harmless the State of South Carolina, its officers and employees, from any loss or expense relating to the payment of such reimbursement.
Sworn to and subscribed before me, this _______ day of _________________ , 20___
________________________________________ Notary Signature
_____________________________________________ Signature of Holder Representative
Name and title of Holder Representative:
Notary Public for ________________________
____________________________________________
My commission expires ___________________
_____________________________________________
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