San Joaquin — Escheatment: Affirmation Form (not for funds held at the State Controller's Office)

Source: https://www.sjcourts.org/sites/default/files/forms/2026-02/AFFIRMATION-FORM-This-is-not-for-funds-held-at-the-State-Controllers-Office.pdf

Superior Court of California, County of San Joaquin Stockton Branch, Accounting Department 180 E Weber Ave, 13 th Floor Stockton, CA 95202

AFFIRMATION FORM – For Funds at the Superior Court

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 their 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. Claimant’s Information: This is not for funds held at the State Controller’s Office LAST NAME OR BUSINESS NAME: FIRST NAME: MIDDLE INITIAL: SSN or FEDERAL TAX ID DATE: CURRENT MAILING ADDRESS: DAYTIME PHONE: CLAIMANT OR AUTHORIZED AGENT SIGNATURE

YOUR SIGNATURE MUST BE NOTARIZED IF THE CLAIM AMOUNT IS $1,000 OR GREATER.

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 their agents, officers, and employees from any loss resulting from the payment of said claims.

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

Superior Court of California, County of San Joaquin Stockton Branch, Accounting Department 180 E Weber Ave, 13 th Floor Stockton, CA 95202

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 toSIGN 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.