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City of Palmdale Finance Department, Accounts Payable Request for Release of Unclaimed Property Form I request the following check be reissued: Check number: Check amount: I was unable to cash the original check issued to me because: I lost it. I never received it. I forgot to cash it. It was destroyed. Other: Company Name (if applicable): My Name: Tax Payer ID number or Social Security Number: As per IRS regulations, Tax Payer ID or Social Security numbers are required for all checks issued. Current Street address: Current City, State, Zip: Current Phone number: Under penalty of perjury, I claim I am the owner of the above described claim and I am the person, or am representing the company, as described in this claim. Signature: Date: Attach: • Copy of official identification, such as a driver’s license, military identification card, or passport. • Proof of the address original check was issued to, such as copy of pay stub, business card, tax return, mortgage statement, telephone or utility bill, bank or credit card statement. If you cannot provide the requested documentation, attach a letter explaining why you are entitled to the unclaimed check and identify any special circumstances that may apply to your claim. We will request additional information if it is needed to process your claim. Special note: If the payee is a minor, or deceased, or the company is in bankruptcy, please contact us regarding additional information that will be required. All information provided will be kept confidential. Send the completed Release of Unclaimed Property form, and all additional documentation, to us via: Email: A/[EMAIL REDACTED] Mail City of Palmdale, Accounts Payable, 38300 Sierra Highway, Suite D Palmdale, CA 93550 [EMAIL REDACTED] Direct questions to (661) 267-5422 or Internal Use Only Form received on: Approved: Date: Replacement check number: Date: Amount: $