Surplus Fund Claimant Intake Form
Virtual Assistant Name:
Jason Diaz
Stellajoy Bantillo
Hannah
Other
Claim Information
Type of Claim
State Funds (Unclaimed Funds)
Tax Overage
State of Claim
California
Connecticut
Nevada
New Mexico
Ohio
Texas
Property ID (PID)
*
Claim Amount
*
Claim Owner's Name
*
First Name
Last Name
Claim Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Holder Name
Property Type
Claimant Information
Claimant's Name (if different than Owner's Name)
*
First Name
Last Name
How the Claimant is related to the Claim Owner
*
Owner/Self
Heir - Spouse of Owner (husband or wife)
Heir - Child of Owner
Heir - Sibling of Owner (sister or brother)
Other - Explain in Notes Section
Claimant's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Claimant's Email
example@example.com
Claimant's Primary Phone Number
*
-
Area Code
Phone Number
Claimant's Secondary Phone Number
-
Area Code
Phone Number
Notes - Please provide any additional information or comments
Today's Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: