Unclaimed Money Refund Form

Unclaimed Money Refund Form

Pursuant to California Government Code Section 50052 the following is submitted:
User Category*
Check Number*
Check Amount $*
Payee Full Name

First NameLast Name
Heir Full Name

First NameLast Name
Business Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Social Security No./ Tax I.D*
Has the claiming user changed residence within the past 2 years?*

NoYes
Please explain the reason for your claim:
Previous Address of Residence

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload a copy of your government issued photo ID or utility bill

Cancelof
Upload a copy of your current Form W-9

Cancelof
Did your company merge with another company?

NoYes
Upload a copy of the merger agreement

Cancelof
Is your company dissolved?

NoYes
Upload a copy of the articles of dissolution

Cancelof
Upload a copy of your Letter or Authorization on Company letterhead with the names of officials with authority to sign and claim on behalf of the business

Cancelof
Upload

Cancelof
NOTICE:

I hereby certify, under penalty and perjury, that the information contained and attached to this claim is true and correct and is being submitted to the City of Paramount to substantiate my claim to money held by the City. I further certify that I have the authority and right to claim and receive payment of said money and hereby release the City of Paramount, its directors, officers, employees, representatives, attorneys, agents, and officials from all liability and further obligation with respect to this claim.
Do you certify*

Yes
Printed Name *
Signature*

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Date*

MonthDayYear
Date
Should be Empty: