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2. Pursuant to California Government Code Section 50052, I wish to file a claim for a previously unclaimed check in the amount of

3. Amount Requesting*
5. The grounds on which I file this claim are:*
7. Vendor or Individual Name
8. Phone Number
10. Electronic Signature
12. Address
14. City
15. State
16. Zip Code
18. Email Address
20. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
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22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit Submit and Print

* indicates a required field