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DEPARTMENT OF FINANCIAL SERVICES
Division of Unclaimed Property
FLORIDA UNCLAIMED PROPERTY AFFIDAVIT - IDENTITY
STATE OF_____________________________
Claim Number ___________________
COUNTY OF __________________________
Total Claimed $ __________________
BEFORE ME, this day, personally appeared the Affiant named in line 1, below, who, being first duly sworn, states as follows:
1. My full name, as shown on the valid, photographic identification issued to me by the United States, a state or territory thereof,
a foreign nation, a political subdivision or agency thereof, or an inmate-in-custody identification card issued by a state or federal
institution of confinement, is:
Printed Name: __________________________.
2. My complete address, as shown on my photographic identification, is:
Street Address: _______________________________ City: ___________________________ State:_____ Zip: ________________.
3. My date of birth, as shown on my photographic identification, is:
Date of Birth: