8290947

UNCLAIMED PROPERTY - JEFFERSON CITY

P. O. Box 1004
Jefferson City MO 65102
(573)751-0123
FAX (573)526-6027
MISSOURI STATE TREASURER RELAY MO/DEAF TTY (800)735-2966
WWW.SHOWMEMONEY.COM

CLAIM FOR ASSETS PRESUMED ABANDONED

THE ITEMS BELOW ARE DOCUMENTS REQUIRED BY THE UNCLAIMED PROPERTY DIVISION TO PROCESS YOUR
CLAIM. RETURN THESE ITEMS TO THE ABOVE ADDRESS.

· Sign and Notarize Claim Form. This form must be mailed - faxed notarizations are not accepted.

· Copy of EACH Claimant's Drivers License (or photo ID) and verification of Social Security number (copy of Social Security Card OR
provide the last 4 digits below)

ORIGINAL OWNER INFORMATION

Property ID Rltn Name Original Address City, State, Zip

15337345 SO WILSON DONALD R 1118 E 4TH ST ATLANTIC , IA 50022-3011

I hereby certify that the above statements herein are complete and that no information has been withheld regarding ownership of the
abandoned account. In the event further inquiries are made regarding this account, I authorize the Office of the Missouri State
Treasurer to refer these individuals to me for resolution of their inquiry/claim. I understand that any falsification or misrepresentation
of this information will be cause for denial of this claim or legal action. Any person who assists in the recovery of property for a fee
without being registered with the State Treasurer will be subject to penalties.

CLAIMANT SIGNATURE:____________________________________________________________ DATE:_______________

**NOTARIZATION**

Subscribed and sworn before me, a notary on this ______ day of _________ , 20___

Notary Public Seal *

CLAIMANT(S) INFORMATION
Claimant I.D. Number 8290947 Social Security
WILSON DONALD XXX-XX-9418
908 WALNUT
(or Federal ID#)
ATLANTIC, IA 50022
Daytime Phone: (712) 249-0390
Email Address:
XX50022@GMAIL.COM

8290947 Page 1 of 1