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   ________________