Form Dfs A4 1944 – Fill Out and Use This PDF

AFFIDAVIT ATTESTING TO CLAIMANT’S IDENTITY

STATE OF _____________________)	Claim Number __________________
COUNTY OF ___________________)

BEFORE ME, this day, personally appeared (1)_________________________________

and (2)_________________________________, who, being first duly sworn, state as follows:

1.We are submitting this sworn statement in connection with the unclaimed property claim filed by

_____________________________________(hereinafter Claimant). We have personal knowledge of Claimant, are familiar with the circumstances of Claimant, personally know and have personally observed Claimant, have experience in dealing with Claimant on a daily basis or as a family member, and know Claimant to be the person named as Claimant in the claim documents. The address of Claimant is ___________________________________

_____________________________________________________________________________________________

2.It is our belief that Claimant does not possess a driver’s license or other photographic identification issued by the United States, a state or territory of the United States, a foreign nation, or a political subdivision or agency thereof. It is our belief that Claimant’s circumstances are such that it would be very difficult or impossible for Claimant to obtain any of the forms of identification specified herein because _________________________________________

_____________________________________________________________________________________________

3. We have no financial interest in the unclaimed property being claimed.

Affiant (1)___________________________	Affiant (2)____________________________
(Signature)	(Signature)
Address ____________________________	Address ______________________________
____________________________	______________________________
Birth date ____________________________	Birth date ____________________________
(month, day, year)	(month, day, year)

Sworn to and subscribed before me this ________ day of _______________, 20______, by Affiants

_____________________________	______________________________________________
(Signature of Notary Public)	(Print, Type, or Stamp Commissioned Name of Notary Public)

______________________________________________________________

(Address of Notary)

____________________________________________________________________________________

(City)

(County)

(State)

(ZIP Code)

*Notary must identify the type of government issued photographic identification produced that verifies Affiants’ names and dates of birth as stated on this form above.

Type of identification shown to Notary by Affiant (such as a drivers license, state identification card, passport, or other similar valid government issued photographic

identification): (1)____________________________

(2)_____________________________

Form DFS-A4-1944, Effective 10-13-10, incorporated into Rule 69I-20.0022, F.A.C.