ARIZONA FORM Arizona Department of Revenue
600A Claim for Unclaimed Property - Original Owner
For assistance in the Phoenix area: (602) 364-0380 or
Outside the Phoenix area toll free: (877) 492-9957
Mail To: Arizona Department of Revenue Unclaimed Property Unit P.O.Box 29026Phoenix, AZ 85038-9026
1. Original Owner's Name: JONATHAN MEANS 2. Property ID: 3986049
3. Original Owner's Social Security or Tax Identification Number
____________________ ____________________
4. Original Owner's Address as reported by holder:
5450 EAST PIPING ROCK ROAD
SCOTTSDALE, AZ 85254
5. Mailing address (Where you would like correspondence, including payment sent)
47 SAINT ANDREWS DR
BEAVER FALLS, NC 15010
In order to initiate a claim for this property the following information must be included:
You must provide a clear copy of your official photo identification or have the claim form notarized below
You must provide proof of your social security number
You must provide proof that you lived or received mail at the address listed above in item #4
Examples of proof include:
Auto Registration or Driver’s License
Birth, Death, Marriage or Stock Certificate
Bank or Utility Statement
Medicare card or insurance Policy
Credit Report
School Transcripts
Court Documents
State Income Tax returns
Postmarked envelope addressed to you
NOTE: Joint owners must each submit a claim form.
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.
7. Claimant’s Name
MEANS
Last Name
JONATHAN, DAVID
First Name, Initial
162664058
Social Security Number ( 602 ) 492 - 6009
Telephone Number
Signature: ____________________________________________ Date: ____________________
Subscribed and Affirmed before me by: _____________________________________
Affix Seal Here
________________________________________________________________
Notary Signature Date
Notary in and for the State of _________________ My Commission Expires ________________