Solano — Claim for Money Held

Source: https://solano.courts.ca.gov/system/files/claim-money-held-cfmh-4801-fillable.pdf

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SOLANO CFMH-4801 2/21 CLAIM FOR MONEY HELD

MAIL TO: Superior Court of California, County of Solano Attention: Fiscal Department (Escheatment) 600 Union Avenue Fairfield, CA 94533

DATE SUBMITTED: __________________________

MONEY HELD INFORMATION:

OWNER’S NAME (AS HELD BY COURT): _____________________________________________

LAST KNOWN ADDRESS: _________________________________________________________

CHECK NO.: _____________ CHECK/ISSUE DATE: _____________ AMOUNT: __________

CLAIMANT’S INFORMATION:

CLAIMANT’S NAME (Should match claim affirmation): _____________________________________

STREET ADDRESS: ______________________________________________________________

CITY, STATE, ZIP CODE: _________________________________________________________

DRIVER’S LICENSE NUMBER: _____________________________________________________

AMOUNT OF CLAIM: $__________________________________________________

RELATIONSHIP TO OWNER: ___________________________________________________

A SEPARATE FORM IS REQUIRED FOR EACH ACCOUNT CLAIMED

AFFIRMATION AND SIGNATURE (by claimant)

I hereby affirm, under penalty of perjury, that I am the rightful payee of the unclaimed monies, and that I am duly authorized to make said claim upon the Superior Court of California, County of Solano. I hereby agree to indemnify and hold harmless the State, the Courts, its officer and employees from any loss, including attorney’s fees, incurred as a result of payment of the amount claimed.

Signature: ________________________________________ Date: ____________________

COURT’s USE ONLY

_____ Approved; Pay to Claimant Shown Above

_____ Denied; Not an Authorized Claim

Recommended by: ____________________________________ Date: ___________________

Hall of Justice Law and Justice Center Solano Justice Center Old Solano Courthouse 600 Union Avenue 530 Union Avenue 321 Tuolumne Street 580 Texas Street Fairfield, CA 94533 Fairfield, CA 94533 Vallejo, CA 94590 Fairfield, CA 94533