Claim Form for Check Refund

Account Owner

Claimant or Name of Person Filing Claim

First

Last

Current Mailing Address (address to which you want check sent)

City

State/Province

Zip/Postal

Email Address

Telephone Number

Social Security Number/Tax ID

Mark one of the following that best describes you:

Are you the owner listed on the first line of this document? If you checked this box, please provide one form of identification for yourself. See below for acceptable forms of identification.

Are you the heir or surviving spouse of the owner of this account? If you checked this box, please attach a copy of death certificate, and will, obituary or notarized list of surviving heirs. Provide one form of identification for yourself. See below for acceptable forms of identification.

Are you the guardian, executor, or administrator of or for the owner of this account? If you checked this box, please attach a copy of the legal document supporting this authority (i.e. power of attorney, court document, birth certificate for owner if the owner is a minor). Provide one form of identification for yourself. See below for acceptable forms of identification.

Are you the officer or other person authorized to claim on behalf of the business entity? If you checked this box, please attach a copy of the corporate resolution or other document verifying your authority (i.e. sales tax license, partnership agreement, proof of DBA).

Acceptable forms of identification: Driver’s license, military ID, other picture ID with identifying information.

If you are required to upload any documents based on your answer to the previous question, upload them here.

Maximum upload size: 52.43MB

Acceptable forms of identification: Driver’s license, military ID, other picture ID with identifying information.

DISCLAIMERS

By checking this box, I agree that if for any reason it is found that I am not entitled to this payment or I receive a duplicate payment, I will return the funds to the City of Beaumont Accounting and Finance Department within 15 days.

I agree that failure to provide my identification, signature, or completion of this claim form will result in me not receiving the unclaimed property.

I acknowledge that by filling out this form electronically, I will receive the unclaimed property by CHECK, mailed to the address I provided above. I understand that cash refunds must be done in person at City Hall, 801 Main Street, 1st floor.