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2. First Name*
3. M.I.
4. Last Name*
6. Claimant SS# / EIN#*
7. Claimant Phone Number*
8. Claimant Email Address
10. Address*
11. Unit/Apt #
13. City/Town*
14. State*
    -- Select One --AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoadoCT - ConnecticutDE - DelawareFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - Wyoming
15. Zip Code*
17. Disclaimer
    Under penalties of perjury, I declare that my claim of ownership to this property is true, absolute and complete.
    
    I (we) have not sold, assigned, transferred, pledged this property, nor given it away nor authorized nor empowered any person or persons, corporation or association to draw any amount on same. Furthermore, I (we) understand that if any taxes or fees are due the Town of Billerica, these funds may not be released and shall be credited to the specific aforementioned in accordance with MGL Ch. 60 § 93 and Ch. 41 § 38A.
19. Claimant Signature*
20. Date*
    Date
22. Co-Owner Signature (if applicable)
23. Date
    Date
25. Signature(s) Note
    By entering your name in the previous field(s), you are effectively signing this document and attesting to the accuracy of the contents contained herein.
27. Notes:
    If payee of unclaimed funds is deceased, please provide evidence that claimant(s) is executor of the estate.
    
    Please note that we may require additional information during the review of your claim.
    
    If all evidence requested is not received, this claim will not be paid.
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29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

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