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Check Replacement Form: S Office of Unclaimed Funds

This document is a check replacement form for the New York State Office of Unclaimed Funds. It requests information to replace a lost, destroyed, expired, or unreceived check, including the claim reference number, name, address, reason for replacement, and signature notarization. Requests to change the address on file require additional verification to prevent fraud. The completed form should be returned, emailed, faxed, or the office contacted for assistance.

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91 views

Check Replacement Form: S Office of Unclaimed Funds

This document is a check replacement form for the New York State Office of Unclaimed Funds. It requests information to replace a lost, destroyed, expired, or unreceived check, including the claim reference number, name, address, reason for replacement, and signature notarization. Requests to change the address on file require additional verification to prevent fraud. The completed form should be returned, emailed, faxed, or the office contacted for assistance.

Uploaded by

john q
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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THOMAS P.

DiNAPOLI 110 STATE STREET


STATE COMPTROLLER ALBANY, NEW YORK 12236

STATE OF NEW YORK


OFFICE OF THE STATE COMPTROLLER
OFFICE OF UNCLAIMED FUNDS

CHECK REPLACEMENT FORM

Use this form to request replacement of a check that is lost, destroyed, expired or not received. We’ll stop payment
on the original check upon receipt of this form. Don’t attempt to cash the original check after submitting this form.

Claim Reference or Confirmation Number(s): _______________________________________________

Name:
FIRST NAME MI LAST NAME

Address:
STREET/PO BOX (The address we currently have on file for you) APT

CITY STATE ZIP

New Address (if applicable):

STREET/PO BOX APT

CITY STATE ZIP

Phone Number: ( ) - Email Address: ______________________________________

Reason for Request (choose one):

Check Not Received Lost Expired Destroyed Damaged (attach actual check)

Other (Please explain)

Requests to change an address have been associated with identity theft and fraud scams. For your protection, claims
with a change of address now require additional verification and documentation before payments can be made.
Your request will not be processed without your signature being acknowledged by a notary public in the space below.

Signature: _______________________________________________________ Date: _________________________

On this ______ day of ____________, in the year 20______, before me ____________________________________________________ (Claimant
Name) personally appeared and is personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name
is subscribed to the within instrument and acknowledge to me that they executed the same in their capacity, and that by their signature, on the
instrument, the individual, or the person upon which the individual acted, executed the instrument.

Notary Signature: _________________________________________________ Notary Stamp:

Return this form to: Contact us: nysouf@osc.state.ny.us or 800-221-9311.


Office of Unclaimed Funds Visit our webpage at http://www.osc.state.ny.us/ouf.
110 State Street
Albany, NY 12236 We invite you to like us on Facebook at:
facebook.com/nyscomptroller
Email: nysouf@osc.ny.gov
Fax: 518-270-2222 Follow us on Twitter at: @NYSComptroller

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