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    sdumclaim_110223(1)

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    Copyright:

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    4 views2 pages

    sdumclaim_110223(1)

    Uploaded by

    jstevenson33

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    © All Rights Reserved
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    South Dakota State Treasurer Unclaimed Property

    ID: 374050
    Return form and attachments to:
    State Treasurer Web Site: www.sdtreasurer.gov
    Unclaimed Property Division Phone: (605) 773-3379
    124 E Dakota Ave Email: [email protected]
    Pierre, SD, 57501

    CLAIM FORM
    Claimant:

    JUSTIN STEVENSON
    104 4TH ST N
    WATERVILLE, MN 56096-1546

    IMPORTANT: The instructions below identify the information you must submit with your
    claim form for it to be processed. Information must be provided for each original owner listed.
    Agreements to locate reported property must comply with SDCL 43-41B-36. Violation of this section is a
    Class 1 misdemeanor. Contact the Unclaimed Property Division if you have questions.

    • Provide a legible photocopy of a driver’s license, passport or other government issued photo ID
    for each claimant.

    • All claimants must sign and date the form.

    • Provide documentation of the Social Security number of all claimants. Example: Copy of Social
    Security card, top portion of tax return, or any other document showing the claimant’s name
    and Social Security number.

    Property ID 1703791 Description ACCOUNTS PAYABLE Year Reported: 2019

    Original Owner(s) Reported to State Treasurer Company Reporting Owner Information to South Dakota Claimant's relationship to this owner
    ____ Original Owner
    STEVENSON JUSTIN GOOGLE INC ____ Guardian or Custodian
    233 BISON TRAIL 1600 Ampitheatre Parkway ____ Representative of business
    DAKOTA DUNES SD 57049 MOUNTAIN VIEW CA 94043 ____ Surviving spouse
    ____ Heir/Executor

    Property Cash $25.28


    Property ID 2430215 Description PREMIUM REFUNDS Year Reported: 2023

    Original Owner(s) Reported to State Treasurer Company Reporting Owner Information to South Dakota Claimant's relationship to this owner
    ____ Original Owner
    STEVENSON JUSTIN PROGRESSIVE NORTHERN INSURANCE ____ Guardian or Custodian
    7601 W SNAPDRAGON ST UNIT 1 6300 WILSON MILLS RD W33 ____ Representative of business
    SIOUX FALLS SD 57106 MAYFIELD VILLAGE OH 44143 ____ Surviving spouse
    ____ Heir/Executor

    Property Cash $10.00


    Property ID 2430216 Description PREMIUM REFUNDS Year Reported: 2023

    Original Owner(s) Reported to State Treasurer Company Reporting Owner Information to South Dakota Claimant's relationship to this owner
    ____ Original Owner
    STEVENSON JUSTIN PROGRESSIVE NORTHERN INSURANCE ____ Guardian or Custodian
    7601 W SNAPDRAGON ST UNIT 1 6300 WILSON MILLS RD W33 ____ Representative of business
    SIOUX FALLS SD 57106 MAYFIELD VILLAGE OH 44143 ____ Surviving spouse
    ____ Heir/Executor

    Property Cash $10.00

    Total Shares: 0.0000 Total $45.28


    November 30, 2024 Page 1 of 2
    ClaimID: 374050 continued.

    ID: 374050

    AFFIDAVIT: Under penalties of perjury, I (we) hereby certify that the foregoing information is true and correct. I (we) further certify that I (we) have not
    received the property claimed, are entitled to it, and know of no other person who claims to be entitled to any portion. I (we) agree to indemnify the State of
    South Dakota and its officers and its employees for any loss or claim whatsoever resulting from the payment of this claim to me (us). We hereby agree to
    repay the State of South Dakota in full if this claim was erroneously filed and payment was made by the State.

    Justin Stevenson Justin Stevenson 11-30-2024


    Signature Print Name Date

    Signature Print Name Date

    Phone Number

    November 30, 2024 Page 2 of 2

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