INSTRUCTIONS

A holder of unclaimed property must complete and submit either the Wyoming Unclaimed Property Holder Reimbursement Form or the NAUPA Holder Reimbursement Form to the State of Wyoming for reimbursement of funds that were paid to the rightful owner (or his/her representative) by the holder.

Please note that Wyoming will accept either the NAUPA or Wyoming Reimbursement Form.

PLEASE CONTACT THE UNCLAIMED PROPERTY DIVISION IMMEDIATELY IF YOU REIMBURSE AN OWNER THAT WAS PREVIOUSLY REPORTED TO THIS OFFICE SO THAT THE ACCOUNT MAY BE FLAGGED TO AVOID DUPLICATE PAYMENTS.

PART I-HOLDER INFORMATION

Enter the holder name, FEIN, address and telephone number.

PART II-CLAIM INFORMATION

Enter all data as it was reported on the Unclaimed Property report to the State to identify the property for reimbursement.

1. 1. Property Code – the universal NAUPA codes for the property reported.
   2. Account/Reference Number – the account/warrant number of the property reported.
   3. Owner(s) Name and Address – the full name(s) and address(es) of the owner(s) as
      reported. If “unknown” at the time of report, designate the same.
   4. Claimant(s) Name and Address – the full name(s) and address(es) of the person(s) filing the claim if different than the owner.
   5. Date Paid to Claimant or Date Account Reactivated – the date the claim was paid to the owner (or representative) or reactivated by the holder.
   6. Amount Paid – the amount of property reported by the holder to the State.
   7. Total of Reimbursement – the amount expected to be reimbursed to the holder by the State.

PART III-HOLDER CERTIFICATE:

This notarized statement must be completed before the State will process the request for reimbursement and make payment.