Fillable REQUEST FOR HOLDER REIMBURSEMENT/REFUND (Nevada State Treasurer)

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REQUEST FOR HOLDER REIMBURSEMENT/REFUND (Nevada State Treasurer)

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State of Nevada Office of the State Treasurer
Unclaimed Property
555 East Washington Avenue, Suite 5200, Las Vegas,
NV 89101-1075
UP-4 (Rev. 12/20/2015)
REQUEST FOR HOLDER REIMBURSEMENT/REFUND
HOLDER INFORMATION
Holder Information:
Tax/FEIN Number:
Mailing Address:
City:
State:
Zip Code:
Contact Person:
Phone Number:
Email Address:
PROPERTY INFORMATION
Report Year:
Report Amount:
Property Type:
Date Paid to Owner:
Amount Paid to Owner:
Number of Shares:
Name as indicated on Report (owner):
Is this Aggregate?
Yes No
Owner Address:
FOR REIMBURSEMENT: COPY OF PROOF OF PAYMENT MADE TO RIGHTFUL OWNER MUST ACCOMPANY REQUEST.
HOLDER INDEMNIFICATION AND AFFIDAVIT
I, , a duly authorized representative of the holder listed above, do hereby certify that the above
listed funds, or other property that was listed in the report filed by the holder have been paid to the rightful owner(s) or their appointed
representative. I agree, upon payment of the above described property, to indemnify the state of Nevada and hold it harmless from all
claims and losses, demands, costs, and other expenses which the State may sustain by reason of turning over property to the holder and
by reason further of its refusal to pay the property to any other person or persons:
FOR AMOUNT REPORTED IN ERROR, A DETAILED EXPLANATION WITH SUPPORTING DOCUMENTATION MUST ACCOMPANY
REQUEST.
Name of Representative (type or print legibly)
Signature of Holder Representative
Notary
(Notary Stamp)
Sworn to and subscribed before me this
day of
20
______
Notary:
___________________________________
My Commission expires:
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REQUEST FOR HOLDER REIMBURSEMENTREFUND (Nevada State Treasurer)

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Completed 20 July 2020

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