HomeMy WebLinkAboutUnclaimed Money - Claim Form Mail form and suporting
documents to:
CITY City of Lake Elsinore
LAIKE T
L.�T Attn:Administrative Services
11 N 1 1Op_L,L 130 S.Main Street
` DREAM EXTREME Lake Elsinore,CA 92530
UNCLAIMED MONEY CLAIM FORM
Pursuant to California Government Code §50052, I wish to file a claim for previously
unclaimed funds in the amount of $ which were published in the
Newspaper on . The grounds on which I am filing this
claim are:
Agent or Individual Name Taxpayer ID No. or Social Security No.
Address City, State, Zip Code
Home or Cell Telephone Work Telephone
I hereby certify that the above information is true and correct and is being submitted to the City
of Lake Elsinore to substantiate my claim to monies paid the the City. I further certify that I
have the authority and right to claim and receive payment of these monies and hereby release
the City of Lake Elsinore, its directors, employees, representatives, attorneys and agents from all
liability and further obligation wiht respect to this claim.
Printed Name of Claimant Signature of Claimant Date Signed
OFFICE USE ONLY
Approved ( ) Denied( ) Assistant City Manager Date
City Manager Date
Department Approval Date
Account Number CRS Number