Filing Instructions
On the request for unclaimed funds the following fields must be filled in completely in order to process your
claim:
• Amount of the check
• Date of the check
• Payee Full Name/Business Name
• Social Security No./Taxpayer I.D. (Optional)
• Street Address, City, State, Zip, Country
• Daytime Phone Number
• Claimant or Authorized Agent Signature
• Date signed
• Address of Residence previous 3 years
Also, if you are filing a claim for which there are multiple payees on the check, please note that each payee
must sign the claim form and submit the required documentation.
In addition, your signature WILL need to be notarized if your claim exceeds $250.00.
You must also provide the following documentation to our office when filing your claim:
Individuals
• A copy of current photo identification for each claimant
• Verification of address, if mailing address if different from original mailing address or photo identification
• If the claimant is deceased, please submit a death certificate and a short certificate verifying executor
information
• If the name of the owner has legally changed, please provide documentation of the name change
• If you have a legal representative, such as an attorney, power of attorney, trustee or guardian, provide
documentation authorizing the representative to act on your behalf and to receive information regarding
the claim
Business
• Copy of current photo identification for the authorized agent signing the form
• Letter of Authorization on Company letterhead with the names of officers or officials with authority to sign
and claim on behalf of the business
• If your company merged with or was acquired by another company, a copy of the merger agreement,
assignment or other document evidencing the right of the successor company to the asset;
• If your company was dissolved, a copy of the articles of dissolution;
Mail the completed claim form and documents to the following address:
County of Delaware
Joanne Phillips, Controller
Attn. Jeffrey Powers, First Deputy Controller
201 W. Front St.
Media, PA 19063
When our office receives your completed claim form, we will review it carefully. If the documentation is not
adequate to prove your ownership or a subsequent payment has been processed, our office will contact you
or return all documents submitted, with a letter stating why the claim is incomplete or being denied. Please
allow 4-6 weeks processing time. If you have any questions, please contact our office at 610-891-5159.
COUNTY OF DELAWARE
REQUEST FOR UNCLAIMED FUNDS
CHECK DATE
CHECK AMOUNT
Each of the undersigned claimants certifies under penalty of perjury that the claimant is the owner of said
unclaimed property and the person entitled to receive the money set forth in the claim.
Furthermore, each claimant agrees to indemnify and hold harmless County of Delaware, its officers, and its
employees from any loss resulting from the payment of this claim.
EACH CLAIMANT (PAYEE) MUST SIGN THIS AFFIRMATION OR THE CLAIM WILL BE RETURNED
PAYEE FULL NAME / BUSINESS NAME
SOCIAL SECURITY NO. / TAXPAYER I.D.
(OPTIONAL)
STREET ADDRESS
CITY
STATE
COUNTRY
DAYTIME PHONE
SIGNATURE REQUIRED
DATE
PAYEE FULL NAME / BUSINESS NAME
SOCIAL SECURITY NO. / TAXPAYER I.D
(OPTIONAL).
STREET ADDRESS
CITY
STATE
COUNTRY
DAYTIME PHONE
SIGNATURE REQUIRED
DATE
YOUR SIGNATURE (S) MUST BE NOTARIZED IF THE CLAIM IS OVER $250
Subscribed and sworn before me this __________day of __________year of_____________
Notary Public in and for
The County of__________________________________, State of ____________________
Send completed affirmation to:
County of Delaware
Joanne Phillips, Controller
Attn. Jeffrey Powers, First Deputy Controller
201 W. Front St.
Media, PA 19063
Previous Addresses
Please list last 3 years
Name:
Date from:
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STATE
ZIP
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STATE
ZIP
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