Marin — ADM027

Source: https://www.marin.courts.ca.gov/system/files/forms-and-filing/adm027-escheatment-claim-instructions-and-forms-3-26.pdf

Superior Court of California, County of Marin

ESCHEATMENT CLAIM INSTRUCTIONS and FORMS

If you are claiming funds, please complete the following:

STEP 1: Fill out the attached forms (Claim Affirmation Form and Claim For Reimbursement). When completing the claim forms, please type or print legibly in blue or black ink. Claims that are illegible will be returned. Claims must be made using the court’s forms. Any modifications made to the court’s forms will not be accepted.

STEP 2: Sign the Claim Affirmation Form and have it notarized if your claim is over $1,000 (or your claim will not be processed). Please read all of the instructions and make copies of all required documents (driver’s license, etc.). Owners or heirs are required to provide documentation to validate their claims.

STEP 3: Claimant is required to fill out a separate Claim Affirmation Form and Claim for Reimbursement for each claim.

STEP 4: Mail, bring to court, or email the completed forms along with all the required materials to: Marin County Superior Court 3501 Civic Center Drive, Room 116 San Rafael, CA 94903 Attn: Finance - Escheatment

For additional questions or to email forms and supporting documentation, email us at Accounting@marin.courts.ca.gov.

For All Claim types, Complete the forms as follows: • Complete and sign the Claim of Affirmation Form. • Notarize your Claim of Affirmation Form, if your claim is over $1,000. • Complete the information located above the “Court Staff Use Only” box on the Claim for Reimbursement form. • Choose one of the 3 options below to complete and attach the necessary supporting documentation.

1. IF YOU ARE THE ORIGINAL OWNER FILING CLAIM

In addition to the signed forms, the following is a checklist of the documentation required when sending in your claim: • Copy of current photo identification for each claimant; • Proof of Social Security number for each claimant; • Proof associating you with the last known address; • Proof associating you to the Court and the reported case, as applicable; and • The original instrument used such as a receipt, invoice, copy of check, correspondence

ADM027 (3/26)

2. IF YOU ARE THE HEIR TO A DECEASED OWNER

In addition to the signed forms, the following is a checklist of the documentation required when sending in your claim:

• Death certificate of the deceased owner(s) of the funds; • Copy of current photo identification for each heir; • Proof of Social Security number for each heir; • Proof associating the deceased owner to the Court and the reported case, as applicable; • The original instrument used such as a receipt, invoice copy of check, etc.; • Proof associating the deceased owner with the last known address; and • If probate of estate is open, the estate tax identification number and a copy of Currently Certified Letters Testamentary, dated within 6 months, appointing the executor or administrator of decedent's estate. OR • If probate of the estate is closed, provide the estate tax identification number and a complete copy of the Court Ordered Distribution of the decedent's estate. OR • Provide a complete copy of the Trust Agreement and a copy of a document with the trust tax identification number, such as a tax return or a bank statement.

3. IF YOU ARE THE AUTHORIZED OWNER OF A BUSINESS CLAIM

In addition to the signed forms, the following is a checklist of the documentation required when sending in your claim:

• Proof associating the business with the Court and the reported case, as applicable; • The original instrument used such as a receipt, invoice, copy of check, etc.; • Letter of Authorization with the names of officers or officials with authority to sign and claim on behalf of the business; • Copy of current photo identification for each authorized officer or official; • Business card of the authorized officer or official; • Proof of the business's federal tax identification number; • Proof of the business's association with the last known address; • If your company merged with another company, a copy of the merger agreement; • If your company was dissolved, a copy of the articles of dissolution; • If your company was suspended, a Tax Clearance letter or a Letter of Good Standing from the Franchise Tax Board and/or the Secretary of State's Office.

ADM027 (3/26)

Marin Superior Court CLAIM AFFIRMATION FORM

CLAIM AFFIRMATION FORM

The undersigned claimant certifies, under penalty of perjury, the claimant has read the claim and knows the contents thereof and the claimant is the owner of the said claim and the person entitled to receive the money set forth in said claim.

The claimant agrees to indemnify and hold harmless the State, the Courts and its agents, officers, and employees from any loss resulting from the payment of said claims.

CURRENT INFORMATION AND SIGNATURE MUST BE PROVIDED FOR EACH CLAIMANT OR YOUR CLAIM WILL NOT BE PROCESSED

Middle SSN or Federal

Last Name or Business First Name Initial Tax ID Date

Current Mailing Address City State Zip Code Country

Daytime Phone Claimant or Authorized Agent Signature

YOUR SIGNATURE MUST BE NOTARIZED IF THE CLAIM AMOUNT IS $1,000 OR GREATER For claims filed for a business, the authorized owner's signature is required. For claims filed for an estate or trust, the signature of the executor, administrator or attorney is required.

State of California County of Subscribed and sworn to (or affirmed)

before me on this day of , 20 , by

, proved to me on the basis of satisfactory evidence to be the

person(s) who appeared before me.

Signature (Seal)

PRIVACY NOTIFICATION

Your Social Security number and other documents are requested for identification and processing of your claim.

ADM027 (3/26)

Marin Superior Court CLAIM FOR REIMBURSEMENT

MAIL TO: Napa Superior Court ATTN: Finance-Escheatment 3501 Civic Center Drive, Room 116 San Rafael, CA 94903

DATE SUBMITTED: OWNER’S NAME: STREET ADDRESS: CITY, STATE, ZIP CODE: REIMBURSEMENT CLAIM: $ CLAIMANT’S NAME (SHOULD MATCH CLAIM AFFIRMATION): RELATIONSHIP TO THE OWNER: EMAIL ADDRESS:

A SEPARATE FORM IS REQUIRED FOR EACH ACCOUNT FOR WHICH REIMBURSEMENT IF CLAIMED.

AFFIRMATION AND SIGNATURE

I hereby affirm, under penalty of perjury, that I am an authorized agent of the holder named in this Claim for Reimbursement and duly authorized to make said claim upon the Superior Court of California, County of Marin. The above-named holder hereby agrees to indemnify and hold harmless the State, the Courts, its officers and employees from any loss as a result of payment of the amount claimed.

SIGN

Signature: Date:

COURT STAFF USE ONLY

Date:

By:

☐ Approved, Paid to Claimant shown above ☐ Denied, Not an authorized Claim

ADM027 (3/26)