Front Office Life Insurance
Resume:
Stacy Garrity, State Treasurer
WILLIAMS HOLLY DEE 1
PO BOX 4375
READING PA 19606
You may be entitled to money from the Pennsylvania Treasury Department’s Bureau of Unclaimed Property -- we want to help you claim what's yours!
Unclaimed property includes things like abandoned bank accounts, forgotten stocks, uncashed checks, certificates of deposit, life insurance policies, safe deposit box contents, and recovered stolen property. It's easy for property to become unclaimed -- it happens all the time! Maybe you've moved, and your insurance company has been unable to locate you. Or you forgot to cash an old rebate check. Whatever the case, your money belongs in your wallet!
Follow these simple steps and return the enclosed form(s).
§ If the claim value exceeds $1,500, sign the claim form in the presence of a notary.
§ Each owner listed in Box A of the Property Description page must sign the enclosed forms. If an owner or beneficiary is deceased, include a certified copy of the death certificate.
§ If the name of the owner listed in Box A of the Property Description page has changed, provide documentation of the name change. Examples of acceptable proof of name change include: marriage license, driver's license, or official court document confirming the name change. Copies are accepted.
§ If an address is listed in Box B of the Property Description page, provide proof of residing at the reported address. Examples of acceptable proof of the reported address include: utility bill, pay stub, bank statement, or any other document confirming the reported address. Copies are accepted.
§ If you are in possession of the original property that is listed in Box F of the Property Description page, such as an uncashed check or stock certificate, please return it along with your form(s).
§ 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.
§ If no estate was opened, or if 5 years has passed since the appointment of a personal representative of the estate, AND if you are a spouse, child, parent, or sibling of the deceased, AND the value of the claim is less than
$11,000, submit a completed and notarized Entitlement by Relationship to Decedent Owner Affidavit (if the owner died a resident of Pennsylvania) OR an Affidavit of Domicile (if the owner died a resident of another state), AND a certified copy of the owner's death certificate. Bureau of Unclaimed Property P.O. Box 1837 Harrisburg, PA 17105-1837 1-800-***-**** RETURN CLAIM FORM AND DOCUMENTATION TO:
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Claim ID 79980099
WILLIAMS HOLLY DEE
January 06, 2022
§ If you are the executor or the administrator of the estate, submit either an original Short Certificate, Letters of Testamentary, or Letters of Administration, updated within the past two years which can be obtained from the Register of Wills office in the county in which the deceased owner resided at the time of his or her death. If you are the administrator of the estate, also complete and submit the enclosed Proposed Distribution Schedule. Additional documentation may be requested to prove you are the rightful owner. Upload your completed claim form by following the online prompts OR Print and mail your completed documents to: Pennsylvania Treasury Department, Bureau of Unclaimed Property, P.O. Box 1837, Harrisburg, PA 17105-1837.
However, the original document(s) must be provided for the following: 1. Bearer bonds
2. Interest coupons or bearer bonds
3. Cashier checks
4. Money order
The original document is required in order to process your claim for the types of documents listed above. Mail the original document(s) with your claim number by regular US Postal or priority mail to: Pennsylvania Treasury Department, Bureau of Unclaimed Property, P.O. Box 1837, Harrisburg, PA 17105-1837. Failure to mail us the original document(s) may result in delayed processing of your claim. Original documents, if not accompanying the claim form, should reference your claim number.
Our Return Team stands ready to assist you at 1-800-***-****. Bureau of Unclaimed Property P.O. Box 1837 Harrisburg, PA 17105-1837 1-800-***-**** RETURN CLAIM FORM AND DOCUMENTATION TO:
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Claim ID 79980099
PROPERTY DESCRIPTION
Property / Holder Information Property ID 1042087
(A) Original Owner's Name
(B) Original Owner's Address as Reported
WILLIAMS HAROLD L P O BOX 15757 HARRISBURG PA 17105-5757
(E) Holder Address and Contact
(C) Holder Reporting Funds
800-***-**** (H) Amount Reported
(G) Certificate, Policy or Check Number
(F) Type of Funds Reported
(D) Last Transaction Date
10/28/1989
JUDIANNE C HYDE
100 ERIE INSURANCE PLACE REFUNDS / REBATES
5.75
ERIE INSURANCE EXCHANGE
ERIE PA 16530
0001456
Property / Holder Information Property ID 5296806
(A) Original Owner's Name
(B) Original Owner's Address as Reported
WILLIAMS HAROLD L PO BOX 93 MILLS PA 16937-0090
(E) Holder Address and Contact
(C) Holder Reporting Funds
800-***-**** (H) Amount Reported
(G) Certificate, Policy or Check Number
(F) Type of Funds Reported
(D) Last Transaction Date
12/15/2003
ABANDONED PROPERTY UNIT
OFFICE OF THE CORPORATE SECRETARY ONE MADISON AVE Demutualization Cash 36.12
METLIFE INC DEMUTUALIZATION (PA)
NEW YORK NY 10123
Property / Holder Information Property ID 5296807
(A) Original Owner's Name
(B) Original Owner's Address as Reported
WILLIAMS HAROLD L PO BOX 93 MILLS PA 16937-0090
(E) Holder Address and Contact
(C) Holder Reporting Funds
800-***-**** (H) Amount Reported
(G) Certificate, Policy or Check Number
(F) Type of Funds Reported
(D) Last Transaction Date
04/05/2000
ABANDONED PROPERTY UNIT
OFFICE OF THE CORPORATE SECRETARY ONE MADISON AVE Demutualization Stock 1,494.25
METLIFE INC DEMUTUALIZATION (PA)
NEW YORK NY 10123
False Total Shares Claimed 0.0000 Total Cash Claimed 1,536.12 Bureau of Unclaimed Property P.O. Box 1837 Harrisburg, PA 17105-1837 1-800-***-**** RETURN CLAIM FORM AND DOCUMENTATION TO:
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Claim ID 79980099
Stacy Garrity, State Treasurer Claim ID 79980099
ENTITLEMENT BY RELATIONSHIP TO DECEDENT OWNER AFFIDAVIT YOUR NAME: YOUR ADDRESS: BEING first duly sworn, (“Claimant(s)”) deposes and represents the following:
(YOUR NAME)
THAT I am entitled to claim unclaimed property held by the State Treasurer as the heir of
(“Owner”), pursuant to Title 20, Section 3101, of the Pennsylvania Consolidated Statutes (see reverse). THAT the deceased Owner was a resident of the Commonwealth of Pennsylvania at the time of death; and THAT the value of this property does not exceed $11,000.00 for the aggregate unclaimed property claim; and THAT my relationship to deceased, who died on _ _ / _ _ / _ _, was that of: Surviving Spouse Child Mother or Father Sister or Brother THAT (1) no petition for the appointment of a personal representative of the deceased is presently pending, OR (2) it has been 5 years or more since the appointment of a personal representative of the deceased; and THAT, in addition to myself, the following individual(s) are also entitled to claim this property because they are also surviving relatives (surviving spouse, other children, parents, or siblings) with the order of preference set forth under Section 3101(e)(1)(ii) of the Pennsylvania Decedent, Estates and Fiduciaries Code (See following page). Name Relationship Address Telephone Number Date of Birth _ _ _ - _ _ _ _ _ _ / _ _ / _ _ _ _ _ - _ _ _ _ _ _ / _ _ / _ _ _ _ _ - _ _ _ _ _ _ / _ _ / _ _ _ _ _ - _ _ _ _ _ _ / _ _ / _ _
(SEE REVERSE)
INSTRUCTIONS:
§ This affidavit must be signed in the presence of a notary.
§ The person signing the affidavit is the claimant. Bureau of Unclaimed Property P.O. Box 1837 Harrisburg, PA 17105-1837 1-800-***-**** RETURN CLAIM FORM AND DOCUMENTATION TO:
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PLEASE NOTE: Pennsylvania law provides that the relatives listed on previous page are entitled to claim the deceased’s property, with preference given in the order listed: (1) surviving spouse, (2) child, (3) mother or father, (4) sister or brother. The claimant to whom payment is made is responsible for distributing the property to any other relative of the deceased having an equal or superior claim. A PAID CLAIMANT'S FAILURE TO DISTRIBUTE PROPERTY IN COMPLIANCE WITH SECTION 3101(e)(1), (2) MAY SUBJECT THE CLAIMANT TO LIABILITY. I acknowledge that by signing this affidavit, I am obligated by law to distribute the deceased's property in compliance with 20 Pa. C.S.A. §3101(e)(3). I further acknowledge and understand that any false information and/or documentation supplied with the claim, will subject me to prosecution under 18 Pa. C.S. §4904, relating to unsworn falsification to authorities; the conviction of which could subject me to a prison term of up to two years and a fine of up to $5000. X
BEFORE ME, the undersigned authority, on this day personally appeared, known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged so he/she executed the same for the purposes and consideration therein expressed and SUBSCRIBED AND SWORN TO ME this the day of A.D. 20 . Notary Signature: Printed Name of Notary: My commission expires:, Telephone Number: - - IMPORTANT NOTICE TO THE NOTARY PUBLIC: All blanks on this form must be completed prior to notarization or the form will be considered incomplete and processing of the claim may be delayed. Additionally, in accordance with the Notary Public Law (57 P.S. § 147 et seq.), a notary public may not act if he/she has a direct or financial interest in the claim. NOTARY STAMP
Bureau of Unclaimed Property P.O. Box 1837 Harrisburg, PA 17105-1837 1-800-***-**** RETURN CLAIM FORM AND DOCUMENTATION TO:
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Claim ID 79980099
20 Pa. C.S.A. § 3101
(Decedents, Estates and Fiduciaries Code)
§ 3101. Payments to family and funeral directors.
* * * *
(e) UNCLAIMED PROPERTY.--
(1) IN ANY CASE WHERE PROPERTY OR FUNDS OWNED BY AN INDIVIDUAL, WHO HAS DIED A RESIDENT OF THIS COMMONWEALTH, HAVE BEEN REPORTED TO THE COMMONWEALTH AND ARE IN THE CUSTODY OF THE STATE TREASURER AS UNCLAIMED OR ABANDONED PROPERTY, THE STATE TREASURER, AT ANY TIME AFTER THE DEATH OF THE INDIVIDUAL, SHALL BE AUTHORIZED UNDER THIS SECTION TO DISTRIBUTE THE PROPERTY OR TO PAY THE AMOUNT BEING HELD IN CUSTODY WHERE ALL OF THE FOLLOWING CONDITIONS ARE PRESENT:
(I) THE AMOUNT OF THE FUNDS OR THE VALUE OF THE PROPERTY IS
$11,000 OR LESS.
(II) THE PERSON CLAIMING THE PROPERTY OR THE FUNDS IS THE SURVIVING SPOUSE, CHILD, MOTHER OR FATHER, OR SISTER OR BROTHER OF THE DECEDENT WITH PREFERENCE GIVEN IN THAT ORDER.
(III) PERSONAL REPRESENTATIVE OF THE DECEDENT HAS NOT BEEN APPOINTED OR FIVE YEARS HAS LAPSED SINCE THE
APPOINTMENT OF A PERSONAL REPRESENTATIVE OF THE
DECEDENT.
(2) UPON BEING PRESENTED WITH A CLAIM FOR PROPERTY OWNED BY A DECEDENT, THE STATE TREASURER SHALL REQUIRE THE PERSON CLAIMING THE PROPERTY TO PROVIDE ALL OF THE FOLLOWING PRIOR TO DISTRIBUTING THE PROPERTY OR PAYING THE AMOUNT HELD IN CUSTODY:
(I) A CERTIFIED DEATH CERTIFICATE OF THE OWNER.
(II) A SWORN AFFIDAVIT UNDER THE PENALTIES OF 18 PA.C.S. § 4904
(RELATING TO UNSWORN FALSIFICATION TO AUTHORITIES), SETTING FORTH THE RELATIONSHIP OF THE CLAIMANT TO THE DECEDENT, THE EXISTENCE OR NONEXISTENCE OF A DULY
APPOINTED PERSONAL REPRESENTATIVE OF THE DECEDENT AND ANY OTHER PERSONS THAT MAY BE ENTITLED UNDER THIS
SECTION TO MAKE A CLAIM TO THE DECEDENT'S PROPERTY.
(III) OTHER INFORMATION DETERMINED BY THE STATE TREASURER TO BE NECESSARY IN ORDER TO DISTRIBUTE PROPERTY OR PAY FUNDS UNDER THIS SECTION TO THE PROPER PERSON.
(3) IF THE STATE TREASURER DETERMINES THE CLAIMANT TO BE A PERSON ENTITLED TO CLAIM PROPERTY OF A DECEDENT OWNER, THE STATE TREASURER SHALL PAY OR DISTRIBUTE SUCH PROPERTY TO THE CLAIMANT AND SHALL THEREBY BE RELEASED TO THE SAME EXTENT AS IF PAYMENT OR DISTRIBUTION HAD BEEN MADE TO A DULY APPOINTED PERSONAL REPRESENTATIVE OF THE DECEDENT AND Bureau of Unclaimed Property P.O. Box 1837 Harrisburg, PA 17105-1837 1-800-***-**** RETURN CLAIM FORM AND DOCUMENTATION TO:
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SHALL NOT BE REQUIRED TO OVERSEE THE APPLICATION OF THE PAYMENTS MADE. ANY CLAIMANT TO WHOM PAYMENT IS MADE SHALL BE ANSWERABLE THEREFORE TO ANYONE PREJUDICED BY AN IMPROPER DISTRIBUTION OR PAYMENT. NOTICE: This document was compiled by the Pennsylvania Treasury Department from public sources and is included for your information. This document is not intended to replace official versions of the cited act, which will be used to settle any disputes. While we have made every reasonable effort to assure the accuracy of this text as printed, it is presented without warranty, either expressed or implied, as to its accuracy, timeliness, or completeness.
Bureau of Unclaimed Property P.O. Box 1837 Harrisburg, PA 17105-1837 1-800-***-**** RETURN CLAIM FORM AND DOCUMENTATION TO:
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Claim ID 79980099
Stacy Garrity, State Treasurer Claim ID 79980099
DECLARATION OF DISTRIBUTION OF UNCLAIMED PROPERTY (Administrators) In accordance with the Pennsylvania State Treasurer’s fiduciary duty under the Disposition of Abandoned and Unclaimed Property Act1 and the Treasurer’s authority to prescribe the unclaimed property claim form2, all Administrators are required to complete this declaration as part of the claim process. I,, hereby swear and declare that all unclaimed property paid by the Pennsylvania Treasury Department for the Estate of distributed as follows: NAME OF
DISTRIBUTEE
(Enter the name of the
person to whom you are
distributing the decedent’s
assets)
RELATIONSHIP
TO DECEDENT
(Enter the relationship
of the Distributee to the
decedent)
PERCENTAGE OF
DISTRIBUTION
(Enter the mathematical
percentage that each
Distributee will receive)
DOLLAR VALUE
OF DISTRIBUTION
(Enter the dollar valuel that
each Distributee will
receive)
AUTHORITY FOR
DISTRIBUTION
(Enter your authority to
claim decedents’s property,
e.g. heir, will, etc.)
TOTAL DISTRIBUTION
(Must include all fees or costs in order to
total the full amount claimed)
The TOTAL PERCENTAGE of DISTRIBUTION must equal 100%. The TOTAL DOLLAR VALUE of DISTRIBUTION must equal the total claim value.
(SEE REVERSE)
Bureau of Unclaimed Property P.O. Box 1837 Harrisburg, PA 17105-1837 1-800-***-**** RETURN CLAIM FORM AND DOCUMENTATION TO:
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Claim ID 79980099
*Please Note: An individual may not both act as an administrator and collect a “Third Party Fee” pursuant to 72 P.S. § 1301.11 (g).
The Proposed Distribution of Unclaimed Property applies only to unclaimed property. No information is necessary concerning any other estate property or distributions. I acknowledge and understand that if any information provided herein is false, I will be subject to prosecution under 18 Pa. C.S.§ 4904 relating to unsworn falsification to authorities, the conviction of which could subject me to a prison term of up to two years and a fine of up to $5,000. X
Signature of Administrator
Date
1 72 P.S. § 1301.14.
2 72 P.S. § 1301.19.
Bureau of Unclaimed Property P.O. Box 1837 Harrisburg, PA 17105-1837 1-800-***-**** RETURN CLAIM FORM AND DOCUMENTATION TO:
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Claim ID 79980099
Stacy Garrity, State Treasurer Claim ID 79980099
AFFIDAVIT OF DOMICILE
STATE OF COUNTY OF I,, being duly sworn, depose and say that I reside at (street address), City or Town, State of, Country, and am acting as the Surviving Heir for the Estate of (Deceased), who died in the State of on / /, and that at the time of his or her death, the decedent's domicile (legal residence) was at (street address) City or Town, State of, Country . THAT my relationship to deceased, who died on _ _ / _ _ / _ _, was that of: Surviving Spouse Child Mother or Father Sister or Brother THAT, in addition to myself, the following individual(s) are also entitled to claim this property because they are also surviving relatives (surviving spouse, other children, parents, or siblings): Name Relationship Address Telephone Number Date of Birth _ _ _ - _ _ _ _ _ _ / _ _ / _ _ _ _ _ - _ _ _ _ _ _ / _ _ / _ _ _ _ _ - _ _ _ _ _ _ / _ _ / _ _ _ _ _ - _ _ _ _ _ _ / _ _ / _ _
(SEE REVERSE)
Bureau of Unclaimed Property P.O. Box 1837 Harrisburg, PA 17105-1837 1-800-***-**** RETURN CLAIM FORM AND DOCUMENTATION TO:
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Claim ID 79980099
THAT the total value of all claims submitted to Treasury for the decedent owner does not exceed $11,000.00; THAT all debts, taxes and claims against the decedent's estate have been paid for; that this Affidavit is made for purposes of securing transfer or delivery of property owned by the decedent at the time of his or her death to the person or persons legally entitled thereto under the laws of the decedent's domicile; and that any apparent inequality in the distribution has been satisfied or provided for out of other assets of the estate; THAT the claimant to whom payment is made is responsible for distributing the property to any other relative of the decedent having an equal or superior claim and is answerable to anyone prejudiced by an improper distribution or payment; and
THAT Claimant(s) acknowledges and understands that any information and/or documentation supplied with the claim, if false, will subject Claimant(s) to prosecution under 18 Pa. C.S. §4904, relating to unsworn falsification to authorities; the conviction of which could subject Claimant(s) to a prison term of up to two years and a fine of up to $5000. X
Signature of Claimant(s)
BEFORE ME, the undersigned authority, on this day appeared, known to me (or introduced to me by ), to be the person whose name is subscribed to the foregoing instrument, and acknowledged so he/she executed the same for the purposes and consideration therein expressed and SUBSCRIBED AND SWORN TO ME this the day of A.D. 20 . Notary Signature: Printed Name of Notary: My commission expires:, Telephone Number: - - IMPORTANT NOTICE TO THE NOTARY PUBLIC: All blanks on this form must be completed prior to notarization or the form will be considered incomplete and processing of the claim may be delayed. Additionally, in accordance with the Notary Public Law (57 P.S. § 147 et seq.), a notary public may not act if he/she has a direct or financial interest in the claim. NOTARY STAMP
Bureau of Unclaimed Property P.O. Box 1837 Harrisburg, PA 17105-1837 1-800-***-**** RETURN CLAIM FORM AND DOCUMENTATION TO:
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Claim ID 79980099
*79980099*
Stacy Garrity, State Treasurer Claim ID 79980099
PLEASE COMPLETE ALL INFORMATION BELOW:
YOUR NAME(S): DATE OF BIRTH: CURRENT MAILING ADDRESS: CITY/STATE/ZIP: DAYTIME PHONE NUMBER: CELL PHONE NUMBER: EMAIL ADDRESS: SOCIAL SECURITY NUMBER: o I AUTHORIZE THE MAILING OF MY PAYMENT TO THE ADDRESS OF THE LAW OFFICE PROVIDED HERE Claimant Information Please Print
Property / Holder Information
CLAIM FORM
Property ID Property Description Cash Claimed Shares Issue Name Holder 1042087 REFUNDS / REBATES 5.75 0.00 ERIE INSURANCE EXCHANGE 5296806 Demutualization Cash 36.12 0.00 METLIFE INC DEMUTUALIZATION (PA) 5296807 Demutualization Stock 1,494.25 0.00 METLIFE INC DEMUTUALIZATI METLIFE INC DEMUTUALIZATION (PA) Bureau of Unclaimed Property P.O. Box 1837 Harrisburg, PA 17105-1837 1-800-***-**** RETURN CLAIM FORM AND DOCUMENTATION TO:
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Claim ID 79980099
BEING first duly sworn, the above claimant(s) deposes and represents as follows: THAT I/we am/are submitting a claim for unclaimed property held by the Pennsylvania Treasury Department ("Treasury"); THAT I/we am/are entitled to the above unclaimed property, presently under the custodial control of Treasury. In consideration of receipt of the above-mentioned property ("property"), I/we agree to indemnify Treasury and hold Treasury and its employees and representatives harmless against any and all claims, costs, expenses (including reasonable attorney fees) or any other loss arising out of the receipt, care, and delivery of the property to me/us, or arising out of Treasury's refusal to deliver the property to any other persons or entities who may, in the future, be determined to be the rightful owner of the property. THAT I/we agree that this Agreement shall be construed in accordance with laws of the Commonwealth of Pennsylvania; and THAT I/we hereby acknowledge and understand that any false information and documentation supplied with the claim, which I/we do not believe to be true, will subject me/us to prosecution and penalties under 18 Pa. C.S. §4904, (relating to unsworn falsification to authorities). X X Signature of Claimant Signature of Additional Claimant(s) IMPORTANT INFORMATION REGARDING YOUR PAYMENT
The Pennsylvania Treasury Department is responsible for custodial care of unclaimed property. It is proactive of Treasury not to allow the forwarding of checks through the United States Postal Service, even if you have a mail forward notice on file with the Post Office. If you have moved, please contact us at 1-800-***-**** to provide your updated mailing address directly. Failure to contact Treasury with your current address may result in delays in receiving your unclaimed property.
BEFORE ME, the undersigned authority, on this day personally appeared, Claimant Name Additional Claimant Name(s)
known to me to be the person(s) whose name(s) is subscribed to the foregoing instrument, and acknowledged so he/she executed the same for the purposes and consideration therein expressed and SUBSCRIBED AND SWORN TO ME this the day of A.D. 20 .
Notary Signature: Printed Name of Notary: My commission expires:, Telephone Number: - -
IMPORTANT NOTICE TO THE NOTARY PUBLIC: All blanks on this form must be completed prior to notarization. Additionally, a notary public may not act if he/she has a direct or financial interest in the claim. Notarization information
Bureau of Unclaimed Property P.O. Box 1837 Harrisburg, PA 17105-1837 1-800-***-**** RETURN CLAIM FORM AND DOCUMENTATION TO:
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Claim ID 79980099
Third Party Information
Was/Is a third party involved in providing this claim form to you/the claimant or assisting with the claim in any way? If so, please state the amount of such fee or payment.
Yes No $ Please specify amount of fee / payment Third Party Information:
Name: Address: Phone Number: Registration Number: Email Address: Please be advised that, effective January 12, 2015, a person may not engage in and receive compensation for any activity for the purpose of locating or assisting in the recovery of unclaimed property on behalf of another, without first obtaining a Certificate of Registration from the State Treasurer, which includes a registration number. For more information, visit www.patreasury.gov. Bureau of Unclaimed Property P.O. Box 1837 Harrisburg, PA 17105-1837 1-800-***-**** RETURN CLAIM FORM AND DOCUMENTATION TO:
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Contact this candidate