"Security Refund Request Form" - New York

Security Refund Request Form is a legal document that was released by the Office of the New York State Comptroller - a government authority operating within New York.

Form Details:

  • The latest edition currently provided by the Office of the New York State Comptroller;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Office of the New York State Comptroller.

ADVERTISEMENT
ADVERTISEMENT

Download "Security Refund Request Form" - New York

Download PDF

Fill PDF online

Rate (4.6 / 5) 7 votes
T
P
D
HOMAS
.
iNAPOLI
110 S
S
TATE
TREET
S
C
TATE
OMPTROLLER
A
N
Y
LBANY,
EW
ORK 12236
S
TATE OF NEW YORK
OFFICE OF THE STATE COMPTROLLER
O
U
F
FFICE OF
NCLAIMED
UNDS
Security Refund Request Form
Reference Number: _________________________________
(Located top right on correspondence from this office)
Complete this form to choose your refund preference for the security portion of your claim. Each
claimant should complete a separate form.
Initial the box next to your preference:
1.
Cash Value:
You’ll receive a check for the current market value of the security, including all
dividends. We use the price per share on the date your claim is approved for payment to
determine the current market value.
(fastest option)
2.
Direct Registration System (DRS) Transfer:
We will transfer your securities into an
account in your name held with the security’s transfer agent. You’ll receive a statement from the
transfer agent reflecting the transfer.
3.
Wire Transfer:
We will transfer the securities to your active brokerage or mutual fund
account. You’ll receive a statement from your agent reflecting the transfer.
Name of Broker or Mutual Fund:
Provide
your
DTC/NSCC Participant Number:
current
broker or
mutual fund
Your Active Account Number:
information
Account Registration:
(Must be in either the claimant’s name or the name of the Estate)
Broker/Mutual Fund Contact Name
and Phone Number:
We’ll send you a check for the cash value if we don’t have the securities in our inventory or if we
can’t transfer the securities as instructed above. We’ll let you know if the securities are worthless or
ineligible for DRS or wire transfer. You may wish to consult with a tax advisor as any security
transaction could have tax consequences.
_______________________________________ _____/______/______ ____________________
Claimant Name
Date of Birth
Taxpayer/Estate ID
____________________________________________ _____/______/______
Claimant Signature (required)
Date
Return this form by mail:
Visit our webpage at http://www.osc.state.ny.us/ouf.
Office of Unclaimed Funds
You can contact us at
nysouf@osc.ny.gov
or 800-221-9311.
110 State Street
Albany, NY 12236
We invite you to like us on Facebook at facebook.com/nyscomptroller
Submit online:
and follow us on Twitter at @NYSComptroller
https://ouf.osc.state.ny.us/ouf/cs
NYS Personal Privacy Protection Law Notification: The NYS Comptroller's Office of Unclaimed Funds (OUF) is requesting you to provide your
Tax Payer Identification Number and/or Date of Birth on this form in order to verify your identity and that you're entitled to claim the funds. OUF is
authorized to collect this information under Section 1406 of the NYS Abandoned Property Law. Disclosing this information is voluntary and we will
process your claim without it. However, in certain cases OUF is required to report the transaction to the Internal Revenue Service and/or other
taxing authorities. If your claim is subject to such a requirement, and you don’t provide the requested information at this time, we’ll require that you
provide such information prior to payment. The information provided will be maintained in the Unclaimed Funds Processing System under the
direction of the Assistant Director of Services of OUF, 110 State Street, Albany, NY 12236
T
P
D
HOMAS
.
iNAPOLI
110 S
S
TATE
TREET
S
C
TATE
OMPTROLLER
A
N
Y
LBANY,
EW
ORK 12236
S
TATE OF NEW YORK
OFFICE OF THE STATE COMPTROLLER
O
U
F
FFICE OF
NCLAIMED
UNDS
Security Refund Request Form
Reference Number: _________________________________
(Located top right on correspondence from this office)
Complete this form to choose your refund preference for the security portion of your claim. Each
claimant should complete a separate form.
Initial the box next to your preference:
1.
Cash Value:
You’ll receive a check for the current market value of the security, including all
dividends. We use the price per share on the date your claim is approved for payment to
determine the current market value.
(fastest option)
2.
Direct Registration System (DRS) Transfer:
We will transfer your securities into an
account in your name held with the security’s transfer agent. You’ll receive a statement from the
transfer agent reflecting the transfer.
3.
Wire Transfer:
We will transfer the securities to your active brokerage or mutual fund
account. You’ll receive a statement from your agent reflecting the transfer.
Name of Broker or Mutual Fund:
Provide
your
DTC/NSCC Participant Number:
current
broker or
mutual fund
Your Active Account Number:
information
Account Registration:
(Must be in either the claimant’s name or the name of the Estate)
Broker/Mutual Fund Contact Name
and Phone Number:
We’ll send you a check for the cash value if we don’t have the securities in our inventory or if we
can’t transfer the securities as instructed above. We’ll let you know if the securities are worthless or
ineligible for DRS or wire transfer. You may wish to consult with a tax advisor as any security
transaction could have tax consequences.
_______________________________________ _____/______/______ ____________________
Claimant Name
Date of Birth
Taxpayer/Estate ID
____________________________________________ _____/______/______
Claimant Signature (required)
Date
Return this form by mail:
Visit our webpage at http://www.osc.state.ny.us/ouf.
Office of Unclaimed Funds
You can contact us at
nysouf@osc.ny.gov
or 800-221-9311.
110 State Street
Albany, NY 12236
We invite you to like us on Facebook at facebook.com/nyscomptroller
Submit online:
and follow us on Twitter at @NYSComptroller
https://ouf.osc.state.ny.us/ouf/cs
NYS Personal Privacy Protection Law Notification: The NYS Comptroller's Office of Unclaimed Funds (OUF) is requesting you to provide your
Tax Payer Identification Number and/or Date of Birth on this form in order to verify your identity and that you're entitled to claim the funds. OUF is
authorized to collect this information under Section 1406 of the NYS Abandoned Property Law. Disclosing this information is voluntary and we will
process your claim without it. However, in certain cases OUF is required to report the transaction to the Internal Revenue Service and/or other
taxing authorities. If your claim is subject to such a requirement, and you don’t provide the requested information at this time, we’ll require that you
provide such information prior to payment. The information provided will be maintained in the Unclaimed Funds Processing System under the
direction of the Assistant Director of Services of OUF, 110 State Street, Albany, NY 12236