ESTATES OF DECEASED PERSONS WITH KNOWN HEIRS CLAIM FORM

HEIR INFORMATION:
Name of Heir: FBO Krystal A. Yager
Address:
City / State / Zip:
Phone:

ESTATE BEING CLAIMED:
Name of Decedent: Estate of Mary Simmons
Amount of Claim: $54.67
Case #: PRMC2100710

DECLARATION OF HEIR:
I hereby certify that I am the rightful heir to the funds on deposit. I declare under penalty of perjury that the foregoing information is correct and the documents I have submitted are either originals or true copies of the originals. I agree to indemnify and hold harmless the County of Riverside, its officers, and its employees from any loss resulting from the payment of this claim.
 
Signature of Heir   Date

NOTARY ACKNOWLEDGEMENT:
State of ______________, County of __________________. On _____________, before me, ______________________ Notary Public, personally appeared ____________________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this document and acknowledged to me that he/she executed this document.

Witness my hand and official seal.

_______________________________________________
Signature 		(seal)

SEND COMPLETED NOTARIZED CLAIM FORM,
COPY OF PHOTO ID & COPY OF HEIR'S BIRTH CERTIFICATE TO:
County of Riverside Office of the Treasurer-Tax Collector
Attn: Fiscal Compliance – Escheated Estates P.O. Box 12005 Riverside, CA 92502-2205