Solano — Unclaimed Funds: Claim Affirmation

Source: https://solano.courts.ca.gov/system/files/claim-affirmation-form.pdf

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SOLANO 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 SIGNATURES MUST BE PROVIDED FOR EACH CLAIMANT OR YOUR CLAIM WILL NOT BE PROCESSED

CLAIMANT’S INFORMATION:

LAST NAME OR BUSINESS NAME FIRST NAME MIDDLE INITIAL SSN OR FEDERAL TAX ID

CURRENT MAILING ADDRESS CITY STATE/PROVINCE ZIP COUNTRY

DAYTIME PHONE CLAIMANT OR AUTHORIZED AGENT SIGNATURE DATE

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

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