C S M T

Approved 1st Level 2nd Level 3rd Level

User

Date

January 31, 2015

Click & Claim

1. Verify Claimant Information
JESSICA LYNN CRUMPLER 24 E PROSPECT ST FRONT ROYAL, VA 22630

*If your name or address is not printed correctly, write the correct information below.

2. Summary of Property to be Claimed
Cash Cash Wages, Payroll, Salary Wages, Payroll, Salary $1 to $50 $1 to $50 Reported by CRACKER BARREL OLD COUNTRY STORE INC Reported by CRACKER BARREL OLD COUNTRY STORE INC ---

3. Provide a photocopy of ALL of the following items
Photo ID - Driver's License or other Photo ID Tax ID - Social Security, Medicare Card or Tax Document with your SSN on it Evidence of Addresses - provide a copy of a bill or other document showing your other addresses: • SHENANDOAH COMMONS WAY, FRONT ROYAL VA

4. Sign the Affidavit below
Under the penalty of perjury, I certify that I (we) am the claimant above; have not received the money or property involved in this claim; am the sole owner of this property and do not know of anyone who claims to receive it or a share of it. I (we) agree to return the property to the State Treasurer if it is later determined that it belongs to someone else, and to reimburse the State for any loss resulting in payment of this claim to me.

Signature as it appears on Identification***

Date

Daytime Phone Number

5. Return completed form
You may return this completed and signed form to us in one of several ways: • Email: ucpmail@trs.virginia.gov • Fax: (804) 692-0576 • Postal: UNCLAIMED PROPERTY DIVISION P.O. BOX 2485 RICHMOND, VA 23218-2485 Staples or paperclips slow down our equipment. Thank you for not using these on anything you send us by mail.

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Contact Information ucpmail@trs.virginia.gov Toll Free: 1-800-468-1088 CLAIMS FAX: 804-692-0576 Virginia Department of the Treasury

Look for us on the web: www.trs.virginia.gov www.VaMoneySearch.org www.facebook.com/VAMoneySearch www.MissingMoney.com

If you would like to receive any cash payments by electronic deposit, please vist the website below for more information and to sign-up: ALLOW UP TO 60 DAYS AFTER WE RECEIVE THIS FORM TO PROCESS YOUR CLAIM. YOU MAY BE ASKED TO SUPPLY ADDITIONAL INFORMATION. IF MORE INFORMATION IS REQUIRED, PLEASE ALLOW ADDITIONAL TIME.

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