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Mining claim form LOCATOR s Form MCF100 Revised July 2005 This form is available from the Arizona Department of Mines Mineral Resources and may be reproduced. Lode Placer 1 mile NE SW SE NW Scale 1 2000 feet 1. The above map depicts the mining claim which is located in Section s Township Range Gila and Salt River Base and Meridian 2. Acquire and maintain mineral rights as described in ADMMR Special Report SR12 Laws and Regulations Governing Mineral Rights in Arizona. The above publications may be ordered from ADMMR or perused at the Department s office and at select Arizona libraries. ADMMR Arizona Department of Mines and Mineral Resources 1502 West Washington Phoenix AZ 85007 Phone 602-771-1600 1-800-446-4259 in Arizona FAX 602-771-1616 www. Determine surface and subsurface ownership status as explained in ADMMR Special Report SR23 Manual for Determination of Status and Ownership Arizona Mineral and Water Rights 3. Claim s was located during the current assessment year. BLM has deferred assessment work attach copy of decision granting deferment or pending petition for deferment including date petition was filed. page 2 say that I am a citizen of the United States more than eighteen years of age that all of the facts set forth in this notice subject to the provisions and penalties of 18 U.S.C. 1001 pertaining to the filing of false fictitious or fraudulent statements with the United States are true and correct according to the best of my knowledge information and belief. MAINTENANCE FEE PAYMENT Claimant Name Address Signature LINE NO. List additional claims on Form MCF114. www. blm.gov/az/ Form MCF112 SUPPLEMENTAL ATTACHMENT May be used with the following forms for listing additional mining claims Check One. mines. az. gov MINING CLAIM FORMS Circular No* 115 revised July 2009 MCF100 MCF112 Location Notice for Lode Mining Claim Claim Map Affidavit of Performance of Annual Work Notice of Intent to Hold Mining Claims/Sites Maintenance Fee Payment Supplemental Attachment for additional claims Notice of Non-liability for Labor and Materials Furnished The forms in this circular may be reproduced for filing with the Bureau of Land Management and the County Recorders office. There are no officially designated forms but the forms provided meet the statutes and the requirements of these agencies. These forms may also be downloaded from the Department website www. mines. az. gov/claimforms. pdf in PDF format. Find the Bureau of Land Management s Maintenance Fee Waiver Certification form 3830-2 at www. blm*gov/pgdata/etc/medialib/blm/az/pdfs. Par. 44542. File. dat/3830-2MaintFee. pdf The following is a brief summary of the filing process for Federal mining claims Mineral rights can be obtained on State or Federal lands that are open to mineral entry. Mining claims leases and mineral material sales apply to Federal Lands. Prospecting permits leases and material sales apply to State Trust Land. The process is complex but can be accomplished by the average citizen* Mining claims cannot be used as a residence or home site.

Report of unclaimed property f... REPORT OF UNCLAIMED PROPERTY FORM A COLORADO DEPARTMENT OF TREASURY UNCLAIMED PROPERTY DIVISION 1580 LOGAN ST SUITE 500 DENVER COLORADO 80203 303-866-6070 OR TOLL FREE 800-825-2111 FAX 303-866-6154 http //www. A. Contact Person for Reporting Telephone Number FAX Email Mailing Address if different from above The following must be completed and signed by a duly authorized officer of the company I affirm and state that I have caused to be prepared ...

Delaware claim for revision 10... O. Box 2340 Wilmington Delaware 19899-2340 LICENSE TAX REV CODE FORM 1049L-9605 THIS FORM TO BE USED TO AMEND GROSS RECEIPTS/EXCISE OR LICENSE TAX RETURNS Enter Account Number 0-000000000-000 Business Code Group Description Business Name Trade Name if Different from Above Business Location Address City A State B TAX PERIOD ENDING GROSS RECEIPTS ORIGINALLY REPORTED Zip Code C CORRECTED AMOUNT Mailing Address if Different D TAX PAID E TAX AMOUNT F ...

Idaho claim of lien form STATE OF IDAHO - NOTICE OF CLAIM OF LIEN IN CROPS FORM SL-1 Name or business name of each producer against whom the lien is claimed and the address of each.

Fill tort claim form Q J State Form 54ssa (3-11) 302 YV- WI-1$ 'i'9i Street. Q ' 9*' Special

Nm affordable housing credit c... RPD-41301 Rev. 9/22/2011 AFFORDABLE HOUSING TAX CREDIT CLAIM FORM State of New Mexico - Taxation and Revenue Department INSTRUCTIONS FOR USING THIS FORM: When claiming the affordable housing tax credit,

Ls 223 form 45 the New York State penal law. affirm that the above statements are true. I authorize the Commissioner of Labor deputies or agents to receive endorse my name on and deposit in the account of the Commissioner of Labor any checks or money orders made out to me as payment on this claim. Signature of Claimant Date Continue Over LS-223 02-08 Commission Salesperson - Note Claims for wages should be recapitulated on Form LS-223. W For Office Use Only Identification Number New York State Department of Labor Division of Labor Standards Refer to wage suppll* I. D. No* if any Claim for Unpaid Wages Please answer all questions on both sides - please print clearly Taken By Section 190. 7 of the New York State Labor Law excludes from wage payment coverage those persons in an administrative executive or professional capacity whose earnings exceed 900 gross per week Note It is necessary for you to have asked for the wages due before we can assist you. 1. Your Full Name Ms. 3. Social Security No* Mr. 2. Your Address Apt. No* City Town or Village County Zip Code 4. Area Code Telephone No* Day Evening 5. Claim against Trade Name of Employer 6. Corporation Name if any 7. Address of main office or headquarters of firm Their positions 9. Names and addresses of responsible persons of firm 11. Is firm still in business 10. Kind of business firm engaged in Yes 13. Address where you worked 12. What was your work or occupation with this firm 15. Name and Position of person hiring you 14. Date Hired 18. Last Day Worked 17. Latest agreed rate of pay per hour per week per day 16. Name of superintendent manager or foreman 19. Status with Firm I No 20. Reason for quitting discharge or layoff quit was discharged was temporarily laid off am still employed 21. Were you a member of any union when employed by this firm If yes give name local no. address zip code and telephone no. of union 22. Have you asked your union for assistance If yes what action has the union taken Before answering questions 23 and 25 first fill out back of this form to help you figure wages due 23. Wages claimed for period first date to last date From To 26. Did you request these wages 25. Total amount of wages due Inclusive 27. Date of Request 28. To whom was the request made 29. Did employer refuse to pay for these wages If yes give employer s reason for refusal 30. Were any payments due you paid by checks returned not honored 31. How were wages paid Cash Check Other Explain If yes submit photocopies of check s What period did this cover Any false statements knowingly made are punishable as a class A misdemeanor Section 210. 1 Commission Salesperson Summary Sheet indicating 1 average weekly earnings including salary draw and commission 2 terms of contract and 3 for commissions claimed to be owing the date of sale customer s name amount of sale rate of commission and commission due. All other employees Wages claimed on other side are to be computed as follows Payroll week ending date Number of hours worked this week of days Rate of pay show whether by hour day week or month Total gross wages earned this Difference between gross wages earned paid to you Gross wages paid to you per 41.

Arizona blank tort claim form North Carolina Industrial Commission IC File # TN.C. Prisoner No.(if applicable) CLAIM FOR DAMAGES UNDER TORT CLAIMS ACT STATE OF NORTH CAROLINA COUNTY OF AFFIDAVIT , being duly sworn, deposes and

Virginia form property For State Use Only CHECK AMOUNT CHECK DEPOSIT DATE INITIALS INTEREST PAYMENT AMOUNT COMMONWEALTH OF VIRGINIA DEPARTMENT OF THE TREASURY Division of Unclaimed Property P O Box 2478 Richmond VA 23218 PHONE 804 225-2393 FAX 804 786-4653 TOLL FREE 1-800-468-1088 Holder Name Address City State Zip Code AP1 FORM FOR REPORT OF UNCLAIMED PROPERTY Contact person Name Title Department Telephone Number FAX Number 2. Please complete the summary information on the reverse of this page and mail your report and remittance to the address at the top of this form. Pursuant to 55-210. 26 1 of the Code of Virginia interest and penalties may be imposed for failure to report and remit as required. REPORT AS TO PROPERTY PRESUMED ABANDONED UNDER THE VIRGINIA UNCLAIMED PROPERTY LAW FOR THE YEAR ENDING AS STATED THAT I AM DULY AUTHORIZED TO EXECUTE THIS VERIFICATION BY THE HOLDER AND BY LAW AND THAT I BELIEVE THAT SAID REPORT IS TRUE CORRECT AND COMPLETE AS OF SAID DATE EXCEPTING FOR SUCH PROPERTY AS HAS SINCE CEASED TO BE ABANDONED. If the address above is incorrect please correct here 3. Please provide e-mail address ABOUT THIS BUSINESS ENTITY Federal Employer Identification Number 5. Standard Industry Code State of Incorporation or locality where business license is filed if not incorporated Annual Gross Income Assets of Employees ABOUT THIS REPORT Date s Due Diligence was Performed This report is for Report Year and the type of report is This report has the following media attached to report the property details DISKETTE/CD HARD COPY-PAPER CONSISTING OF PAGES REPORT UPLOADED TO WEBSITE This is the first time this business entity has filed an Unclaimed Property Report NO Property types on this report include CASH SECURITIES REGULAR MUTUAL FUNDS AUDIT YES NEGATIVE OTHER TANGIBLE PROPERTY IMPORTANT NOTICE Your remittance must accompany this report and an authorized representative of your business must complete the certification that follows. Please complete the summary information on the reverse of this page and mail your report and remittance to the address at the top of this form* Pursuant to 55-210. 26 1 of the Code of Virginia interest and penalties may be imposed for failure to report and remit as required* REPORT AS TO PROPERTY PRESUMED ABANDONED UNDER THE VIRGINIA UNCLAIMED PROPERTY LAW FOR THE YEAR ENDING AS STATED THAT I AM DULY AUTHORIZED TO EXECUTE THIS VERIFICATION BY THE HOLDER AND BY LAW AND THAT I BELIEVE THAT SAID REPORT IS TRUE CORRECT AND COMPLETE AS OF SAID DATE EXCEPTING FOR SUCH PROPERTY AS HAS SINCE CEASED TO BE ABANDONED. THIS REPORT TOTALS PROPERTIES FOR AND SHARES* SIGNATURE TITLE DATE CASH PROPERTY ACCOUNT BALANCES DUE AC01 AC02 AC03 AC04 AC05 AC06 AC07 AC08 AC09 AC21 AC99 CHECKING ACCOUNTS SAVINGS ACCOUNTS MATURED CD OR SAVINGS CERTIFICATE CHRISTMAS CLUB FUNDS MONEY ON DEPOSIT TO SECURE FUND SECURITY DEPOSIT UNIDENTIFIED DEPOSITS SUSPENSE ACCOUNTS SHARE ACCOUNTS MISCELLANEOUS DEPOSITS AGGREGATE ACCOUNT BALANCES 100 UNCASHED CHECKS CK01 CK02 CK03 CK04 CK05 CK06 CK07 CK08 CK09 CK10 CK11 CK12 CK13 CK14 CK15 CK16 CK99 CASHIER S CHECKS CERTIFIED CHECKS REGISTERED CHECKS TREASURER S CHECKS DRAFTS WARRANTS MONEY ORDERS TRAVELER S CHECKS FOREIGN EXCHANGE CHECKS EXPENSE CHECKS PENSION CHECKS CREDIT CHECKS OR MEMOS VENDOR CHECKS CHECKS WRITTEN OFF TO INCOME OTHER OUTSTANDING OFFICIAL CHECKS CD INTEREST CHECKS AGGREGATE UNCASHED CHECKS 100 MS01 MS02 MS03 MS04 MS05 MS06 MS07 MS08 MS09 MS10 MS11 MS12 MS13 MS14 MS15 MS16 MS17 MS18 MS19 MS20 MS99 WAGES PAYROLL SALARY COMMISSIONS WORKERS COMPENSATION BENEFITS PAYMENT FOR GOODS SERVICES CUSTOMER OVERPAYMENTS UNREFUNDED OVERCHARGES ACCOUNTS PAYABLE CREDIT BALANCES A/R DISCOUNTS DUE REFUNDS DUE UNREDEEMED GIFT CERTIFICATES UNCLAIMED LOAN COLLATERAL PENSION PROFIT SHARING PLANS IRA KEOGH DISSOLUTION OR LIQUIDATION MISC OUTSTANDING CHECKS MISC INTANGIBLE PROPERTY SUSPENSE LIABILITIES OTHER CASH Rental Property Income AGGREGATE MISC PROPERTY 100 COURT LOCALITY FUNDS CT01 CT02 CT03 CT04 CT05 CT07 ESCROW FUNDS CONDEMNATION AWARDS MISSING HEIRS FUNDS OTHER COURT DEPOSITS EVIDENCE MONEY CT08 CT09 CT10 CT11 CT12 CT13 CT14 CT15 CT16 CT99 GENERAL RECEIVER ACCOUNTS COURT ORDERED REFUNDS PERSONAL PROPERTY TAX OVERPAYMENT REAL ESTATE TAX OVERPAYMENT COURT HELD ACCOUNTS BONDS LITIGATIONS RESTITUTIONS AGGREGATE COURT DEPOSITS 100 SAFE DEPOSIT BOXES SAFEKEEPING SD01 SD02 SD03 INSURANCE IN01 IN02 IN03 IN04 IN05 IN06 IN07 IN08 IN09 IN10 IN11 IN99 INDIVIDUAL POLICY BENEFITS OR CLAIMS PD GROUP POLICY BENEFITS OR CLAIMS PAID PROCEEDS DUE BENEFICIARIES PROCEEDS FROM MATURED POLICIES ENDOWMENTS PREMIUM REFUNDS OTHER AMOUNTS DUE UNDER POLICY TERMS AGENT CREDIT BALANCES ANNUITIES DEMUTUALIZATION CASH AGGREGATE INSURANCE PROPERTY 100 TRUST INVESTMENT AND ESCROW ACCOUNTS TR01 TR02 TR03 TR04 TR05 TR06 TR99 PAYING AGENT ACCOUNTS UNDELIVERED OR UNCASHED DIVIDENDS FUNDS HELD IN FIDUCIARY CAPACITY ESCROW ACCOUNTS TRUST VOUCHERS AGGREGATE TRUST PROPERTY 100 UTILITIES UT01 UT02 UT03 UT04 UT99 UTILITY DEPOSITS MEMBERSHIP FEES REFUNDS OR REBATES CAPITAL CREDIT DISTRIBUTIONS AGGREGATE UTILITY PROPERTY 100 MINERAL PROCEEDS MINERAL INTERESTS Mi01 MI02 MI03 MI04 MI05 MI06 MI07 MI08 MI09 MI99 NET REVENUE INTEREST ROYALTIES OVERRIDING ROYALTIES PRODUCTION PAYMENTS WORKING INTEREST BONUSES DELAY RENTALS SHUT-IN ROYALTIES MINIMUM ROYALTIES TOTAL ITEM COUNT TOTAL OF OWNERS SECURITY PROPERTY SC01 SC02 SC03 SC04 SC05 SC06 SC07 SC08 SC09 SC10 SC11 SC12 SC13 SC14 SC15 SC16 SC17 SC18 SC19 SC20 SC21 SC97 SC99 TOTAL OF ITEMS DIVIDENDS INTEREST BOND COUPONS PRINCIPAL PAYMENTS EQUITY PAYMENTS PROFITS FUNDS PAID TO PURCHASE SHARES FUNDS FOR STOCKS AND BONDS SHARES OF STOCK RETURNED BY POST OFFICE CASH FOR FRACTIONAL SHARES UNEXCHANGED STOCK OF SUCCESSOR CORP OTHER CERTIFICATES OF OWNERSHIP UNDERLYING SHARES OR OTHER STANDING CERTIFICATES FUNDS FOR LIQUIDATION/REDEMPTION OF UNSURRENDERED STOCK OR BONDS DEBENTURES US GOVT SECURITIES WARRANTS RIGHTS MATURED BOND PRINCIPAL DIVIDEND REINVESTMENT PLANS LIQUIDATED MUTUAL FUND SHARES MUTUAL FUND IRA/RETIREMENT ACCTS AGGREGATE SECURITY RELATED CASH 100 TOTAL SHARES REMITTED TOTAL CASH REMITTED OTHER SAFEKEEPING OTHER TANGIBLE PROPERTY ZZZZ PROPERTIES NOT IDENTIFIED ABOVE.

Total loss report fillable for... Click here to START or CLEAR, then hit the TAB button Total Loss Claim Settlement Report Insurance companies must notify us within 15 days of settling a total loss claim on a vehicle. To do so, submit

Probate f form DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13033 07/08 STATE OF WISCONSIN Wisconsin Statutes Section 859. 07 PROBATE CLAIMS NOTICE Completion of this form is required according to Wisconsin Statutes ss. 859. DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13033 07/08 STATE OF WISCONSIN Wisconsin Statutes Section 859. 07 PROBATE CLAIMS NOTICE Completion of this form is required according to Wisconsin Statutes ss. 859. 07 2 867. 01 3 d and 867. 02 2 d. Personal identifying information will only be used in the administration of the Estate Recovery Program and will not be disclosed to other agencies. Failure to complete this form is covered under Wisconsin Statutes ss. 859. 02 and 865. 17. In the Matter of the Estate of Name of Deceased County Social Security Number Type of Probate Date of Death File Number Date of Birth Final Date to File Claims Check here if the Deceased received any of the following Medicaid benefits under s. 49. 46 or 49. 47 Wis. Stats. Medicaid Community Waiver Program s benefits under s. 46. 27 through 46. 278 Wis. Stats. Medicaid or Non-Medicaid Family Care benefits under s. 46. 286 Wis. Stats. Medicaid Purchase Plan MAPP benefits under s. 49. 472 Wis. Stats. Wisconsin Community Options Program COP benefits under s. 46. 27 Wis. Stats. Wisconsin Chronic Disease Program WCDP benefits under s. 49. 68 through 49. 685 Wis. Stats. Check here if a predeceased spouse of the Deceased received any of the following and include his/her name and Name of predeceased Spouse SSN of predeceased Spouse Disclosure of Social Security Number of a Medicaid recipient is mandatory per 42 U*S*C. 1320b-7 identification of COP and WCDP recipients and for the administration of the Estate Recovery Program Name of Personal Representative/Petitioner Mailing Address Name of Attorney PROOF OF MAILING I being duly sworn on oath certify that on the day of mailed via the U*S* Postal Service by registered or certified mail a true and correct copy of this Notice to the State of Wisconsin and to the County Clerk of the decedent s county of residence and I have filed the original Notice with the Register in Probate for the county listed above as required by ss. 859. 07 867. 01 and 867. 02 Wis. Stats. They have been mailed as follows Original to Register in Probate of county listed above Copy to Department of Health Services Estate Recovery Program Section P. O. Box 309 Madison WI 53701-0309 COUNTY CLERK of the decedent s county of residence Subscribed and sworn to before me on Signature Notary Public/Court Official My commission expires Reset Form. 07 PROBATE CLAIMS NOTICE Completion of this form is required according to Wisconsin Statutes ss. 859. 07 2 867. 01 3 d and 867. 02 2 d. Personal identifying information will only be used in the administration of the Estate Recovery Program and will not be disclosed to other agencies. 07 2 867. 01 3 d and 867. 02 2 d. Personal identifying information will only be used in the administration of the Estate Recovery Program and will not be disclosed to other agencies. Failure to complete this form is covered under Wisconsin Statutes ss. 859. 02 and 865. 17. In the Matter of the Estate of Name of Deceased County Social Security Number Type of Probate Date of Death File Number Date of Birth Final Date to File Claims Check here if the Deceased received any of the following Medicaid benefits under s.

Canada life form claim Supplementary Claim Form Instructions for completion 1. Complete Claimant s Statement below. 2. Have your physician complete and sign reverse side of this form. 3. Return completed form to the appropriate Canada Life claims office listed below. Claimant s Statement Name Loan number Date 1. Supplementary Claim Form Instructions for completion 1. Complete Claimant s Statement below. 2. Have your physician complete and sign reverse side of this form* 3. Return completed form to the appropriate Canada Life claims office listed below. Claimant s Statement Name Loan number Date 1. Have you returned to work day month year Yes state date you returned to work No state date you expect to return to work 2. If not at work what is your general condition at this time 3. If not self-employed is your employer holding your job open for you Yes No I hereby authorize and request all medical practitioners who may have attended me and all hospitals government authorities pension boards employers or other persons to furnish The Canada Life Assurance Company or its accredited representatives all information in their possession or within their knowledge and to honour a photostatic copy of this authorization* I hereby appoint Canada Life as my agent or representative for the purpose of obtaining the above mentioned information* Signature of insured Please submit completed form to Creditor Insurance 330 University Avenue Toronto ON M5G 1R8 Telephone No* 416 597-1440 Toll Free No* 1-800-387-2671 Fax No* 416 552-6557 10231 CAN 11/05 1. Any charge for completing this form is the patient s responsibility. 2. Please print* Attending Physician s Supplementary Statement Patient s name 1. Diagnosis of present condition 2. Objective signs results of recent tests and/or examinations 3. Indicate complications or new independent conditions which may prolong the absence from work. 4. Date of latest attendance Date of hospital admission 5. Have you been actively supervising this patient s care Yes state frequency of visits Weekly Monthly No please advise name s of attending physician s Date of discharge Other specify 6. To aid in assessing this claim do you recall completing similar statements for other insurance companies No Yes give insurer s name 7. a Indicate present treatment program b Is patient following recommended treatment program No please comment 8. To the best of your knowledge is the patient unable to work at own occupation Yes give approximate date when patient should estimated number of weeks before possible return be able to return to work day month year or No give date patient could have returned to work day month year 9. Physical impairment What physical limitations affect the patient s ability to work eg. limitations with respect to lifting standing carrying bending walking etc* 10. How long was or will patient be able to work part-time at own occupation at light or modified duties at any occupation 11. Remarks Please provide comments and further details which you feel would be helpful Name of attending physician please print Specialty Telephone no.

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