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EXHIBIT IV-Sample Claimant Form <br /> <br />TOWN OF LOS ALTOS HILLS <br />UNCLAIMED PROPERTY-CLAIM FORM <br />Return completed form to: <br />Town of Los Altos Hills <br />Administrative Services Department <br />Accounts Payable <br />26379 Fremont Road <br />Los Altos Hills, CA 94022 <br />Pursuant to California Government Code Section 50052, I wish to file a claim for a previously unclaimed <br />check in the amount of $_____________that was published in the Town Crier on _______________ (if <br />applicable). <br />The grounds on which I file this claim are as follows: <br />______________________________________________________________________________ <br />__________________________ ___________________________________ <br />Vendor or Individual Name (printed) Taxpayer I.D. or Social Security Number <br />_____________________________ ___________________________________ <br />Vendor or Individual Name (signature) Telephone Number <br />______________________________________________________________________________ <br />Address City/State/Zip Code <br />NOTE: ALL CLAIMS MUST BE RECEIVED BY THE TOWN BEFORE THE DATE SPECIFIED <br />IN THE NOTICE OR WITHIN 12 MONTHS IF THE AMOUNT IS LESS THAN 15 DOLLARS <br />OR THE DEPOSITORS NAME IS UNKNOWN. POSTMARKS WILL BE ACCEPTED. <br />FOR FINANCE DEPARTMENT USE ONLY <br />Date Claim Received: ________________ <br />Name of Payee: _________________ Original Check Amount: _______________ <br />Original Check #:________________ Original Check Date: __________________ <br />Replacement Check #:________________ Replacement Check Date: ______________ <br />Replacement Check Amount: __________ Account Code: _______________________ <br /> <br />Verified by: _________________________ Date Approved: ______________________ <br /> <br />Resolution 31-20 Page 9