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    Antonio Brookins
    Aaron Brookins is filing a claim for unclaimed property in the amount of $45.85 that is being held by the state of Florida under the name of Arron Antonino Brookins. The unclaimed property is a cash balance from wages earned at Chipotle Mexican Grill. The document provides instructions for Aaron Brookins to complete the claim form and provides the necessary documentation required, which includes a copy of his driver's license or other photo ID, as well as documentation to prove his identity and relationship to the property owner.

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    Antonio Brookins
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    Aaron Brookins is filing a claim for unclaimed property in the amount of $45.85 that is being held by the state of Florida under the name of Arron Antonino Brookins. The unclaimed property is a cash balance from wages earned at Chipotle Mexican Grill. The document provides instructions for Aaron Brookins to complete the claim form and provides the necessary documentation required, which includes a copy of his driver's license or other photo ID, as well as documentation to prove his identity and relationship to the property owner.

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    Aaron Brookins is filing a claim for unclaimed property in the amount of $45.85 that is being held by the state of Florida under the name of Arron Antonino Brookins. The unclaimed property is a cash balance from wages earned at Chipotle Mexican Grill. The document provides instructions for Aaron Brookins to complete the claim form and provides the necessary documentation required, which includes a copy of his driver's license or other photo ID, as well as documentation to prove his identity and relationship to the property owner.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    653 views2 pages

    PDF

    Uploaded by

    Antonio Brookins
    Aaron Brookins is filing a claim for unclaimed property in the amount of $45.85 that is being held by the state of Florida under the name of Arron Antonino Brookins. The unclaimed property is a cash balance from wages earned at Chipotle Mexican Grill. The document provides instructions for Aaron Brookins to complete the claim form and provides the necessary documentation required, which includes a copy of his driver's license or other photo ID, as well as documentation to prove his identity and relationship to the property owner.

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    of 2

    CLAIM NUMBER : C8178858 Form DFS-UP-107

    AARON BROOKINS If your address has changed, enter new address here :
    PO BOX 1285
    _____________________________________________
    LUTZ, FL 33548
    _____________________________________________

    Claim for Unclaimed Property Pursuant to Section 717.124, Florida Statutes - CLAIM FILED BY OTHER THAN THE APPARENT OWNER
    **************************************************************************************************************
    NAME OF OWNER(S) : TYPE :
    BROOKINS, ARRON ANTONINO PRIMARY
    DESCRIPTION OF REPORTED PROPERTY :
    CLAIM AMOUNT : $45.85 CASH BALANCE : $45.85
    ACCOUNT NUMBER : 126775201
    COMPANY NAME : CHIPOTLE MEXICAN GRILL INC
    TYPE OF PROPERTY : WAGES, PAYROLL, SALARY
    **************************************************************************************************************
    TO FILE YOUR CLAIM, FOLLOW STEPS 1 THROUGH 8.

    1. COMPLETE the following information. NOTE: Please provide the following information(use separate sheet, if needed)for each
    heir/beneficiary.
    Claimant's Social Security Number or FEID Number : _______________________
    Telephone Number - Home : (________)________-______________ Office : (________)________-______________

    2. ATTACH a certified copy of death certificate for the reported owner(s).

    3. ATTACH the following as proof of ownership of the property :


    Copy of Social Security Card, medicare card, W-2 Wage and Earnings statement, tax return or another official document that has name and
    Social Security number. For business/corporation accounts, attach a copy of an official document that has name and Federal Employer
    Identification number.

    4. Each Claimant shall provide the Department with a legible copy of a valid driver's licence of the claimant at the time the original claim form is
    filed. If the claimant has not been issued a valid driver's license at the time the original claim form is filed, the Department shall be provided with
    a legible copy of a photographic identification of the claimant issued by the United States or a foreign nation, a state or territory of the United
    States or foreign nation, or a political subdivision or agency thereof. In lieu of photographic identification, a Notarized Sworn Statement by the
    Claimant, Form DFS-A4-2007, may be provided which affirms the claimant's identity and states the claimant's full name and address.

    5. If the estate is still open, attach a court order reflecting the personal representative's right to act for the estate of the apparent
    owner.NOTE:EACH HEIR/BENEFICIARY MUST COMPLY WITH PARAGRAPH 4. A PERSONAL REPRESENTATIVE MAY
    NOT CLAIM UNCLAIMED PROPERTY REGARDING AN HEIR/BENEFICIARY THAT HAS NOT BEEN LOCATED.

    6. If the estate is closed, attach a probate court order identifying the heir(s), together with any additional information needed to identify the heir(s)
    or the relative interests in the unclaimed property of the heir(s). Normally, a copy of the probated will, petition for discharge, order of discharge,
    and a copy of docket sheet will sufficiently satisfy this requirement. In some cases, an order of distribution will be required by this office. If the
    estate was not probated, you may wish to contact the probate court to see if you are eligible to make application for disposition of personal
    property without administration. NOTE: EACH HEIR/BENEFICIARY MUST COMPLY WITH PARAGRAPH 4.

    7. A court order is not required for named beneficiaries of insurance policies and bank accounts.

    8. SIGN AND DATE THE CLAIM FORM. NOTE: EACH CLAIMANT MUST SIGN THE CLAIM FORM.(See back of this form.)

    Effective 01/03/2005 You may check the status of your Claim on-line at www.fltreasurehunt.org
    CLAIM NUMBER : C8178858

    CLAIMANT AFFIRMATION
    Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it are true; that all supporting
    documentation is valid and unaltered; that the unclaimed property is due and owing to the claimant; and that I am authorized to file this claim. I
    authorize the Division of Unclaimed Property to provide my name and address, as payee of the claimed property, to any claimant who may later
    come forward with the substantiated proof to claim the property of this claim.By submitting this claim, I acknowledge that the Department will
    use physical and electronic process to verify the information submitted.

    ____________________________________ _________________________________ ______________


    Claimaint's Printed Name Claimant's Signature Date

    ____________________________________ _________________________________ ______________


    Joint Claimant's Printed Name Joint Claimant's Signature Date

    Once your fully-completed claim form is received with all the required documentation, it will be deemed complete. Please allow up to 90 days
    from the date your claim is deemed complete for the Division of Unclaimed Property to make a decision on your claim. FAILURE TO
    PROPERLY COMPLETE THIS CLAIM FORM AND TO INCLUDE REQUIRED DOCUMENTATION WILL RESULT IN YOUR
    CLAIM BEING RETURNED TO YOU WITH INSTRUCTIONS TO PROVIDE ADDITIONAL INFORMATION.
    Please return ALL pages of this completed claim form to :
    Department of Financial Services, Division of Unclaimed Property, P.O.Box 8599, Tallahassee, FL 32314-8599
    Phone: 888-258-2253 (Inside Florida) (850)413-5555 (Outside Florida) URL: http://www.fltreasurehunt.org
    You may check the status of your claim on-line at www.fltreasurehunt.org

    PLEASE DO NOT STAPLE THE DOCUMENTS

    The Department requests social security numbers in order to determine entitlement to unclaimed property pursuant to section 717.126, Florida
    statutes; to safeguard against fraudulant unclaimed property claims; and for the payment of claims. Social security numbers provided to the
    Department in connection with the claims are kept confidential and will not be released as public records.

    Effective 01/03/2005 You may check the status of your Claim on-line at www.fltreasurehunt.org

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