Submit a Claim - Page 1

Contact Information
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Please Note: Select "Corporation/Other" if you are filing on behalf of an IRA.

Beneficial Owner's Name

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Joint Beneficial Owner's Name (If applicable, provide all information)

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Beneficial Owner's Social Security Number (Last 4):
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Please Note: If this claim is being submitted for an IRA, and if you would like any check that you MAY be eligible to receive made payable to the IRA, please include your name and “IRA” in the "Business/Entity Name" field (e.g., John Jones IRA).

Taxpayer Identification Number (Last 4):
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Alternative :
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Please Note: An email address is required to submit your claim online. If you do not wish to authorize the Claims Administrator to use an email address in providing you with information relevant to this claim, please download and submit a Claim Form via US. Mail.

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