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  1. ARIZONA FORM    Arizona Department of Revenue  
  2. 600A    Claim for Unclaimed Property - Original Owner
  3. For assistance in the Phoenix area: (602) 364-0380 or
  4. Outside the Phoenix area toll free: (877) 492-9957
  5.  
  6. Mail To: Arizona Department of Revenue Unclaimed Property Unit P.O.Box 29026Phoenix, AZ 85038-9026
  7.  
  8. 1. Original Owner's Name: JONATHAN MEANS        2. Property ID:  3986049
  9. 3. Original Owner's Social Security or Tax Identification Number
  10.     ____________________      ____________________
  11. 4. Original Owner's Address as reported by holder:
  12.     5450 EAST PIPING ROCK ROAD
  13.     SCOTTSDALE, AZ 85254
  14. 5. Mailing address (Where you would like correspondence, including payment sent)
  15.     47 SAINT ANDREWS DR
  16.     BEAVER FALLS, NC 15010
  17.  
  18. In order to initiate a claim for this property the following information must be included:
  19.  
  20.   You must provide a clear copy of your official photo identification or have the claim form notarized below
  21.  
  22.   You must provide proof of your social security number
  23.  
  24.   You must provide proof that you lived or received mail at the address listed above in item #4
  25.     Examples of proof include:
  26.     Auto Registration or Driver’s License
  27.     Birth, Death, Marriage or Stock Certificate
  28.     Bank or Utility Statement
  29.     Medicare card or insurance Policy
  30.     Credit Report       
  31. School Transcripts
  32. Court Documents
  33. State Income Tax returns
  34. Postmarked envelope addressed to you
  35.  
  36. NOTE: Joint owners must each submit a claim form.
  37.  
  38. Declarations: I swear under penalty of perjury that statements I made on this claim form and any other statements that I made or will make during the claims process are true and correct to the best of my knowledge. Photocopies I have provided or will provide are the same as the original document. I understand that additional evidence may be needed to process my claim and that the claims processing staff may contact me in that case. I agree that if for any reason it is found that I am not entitled to this payment or I receive a duplicate payment, I will return the funds to the Arizona Department of Revenue within 15 days.
  39.  
  40. 7. Claimant’s Name
  41.     MEANS
  42.     Last Name
  43. JONATHAN, DAVID
  44. First Name, Initial
  45.     162664058
  46.     Social Security Number     ( 602 ) 492 - 6009  
  47. Telephone Number
  48.  
  49.     Signature:    ____________________________________________     Date:    ____________________
  50.  
  51.  
  52. Subscribed and Affirmed before me by: _____________________________________    
  53. Affix Seal Here
  54.  
  55.  
  56.  
  57.  
  58.  
  59. ________________________________________________________________
  60. Notary Signature                                                                  Date
  61.  
  62.  
  63. Notary in and for the State of   _________________   My Commission Expires   ________________