Pursuant to California Government Code 50052, I wish to file a claim for unclaimed funds in the amount of:

Enter amount in the following format: $123.45

Please Check One:*

I am the PAYEE listed on your website. I am an HEIR OF THE DECEASED PAYEE listed on your website. I am an Agent/Officer for the BUSINESS listed on your website. I am the Agent/Officer for the GOVERNMENT AGENCY listed on your website.

The grounds on which this claim is founded:

First Name:*

Last Name:*

Service Address:

Number & Street

Apt./Suite No.

City

State

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Zipcode

Current Mailing Address:

Number & Street

Apt./Suite No.

City

State

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zipcode

Current Telephone Contact Number:

Printed Name of Claimant:

By checking this box, I hereby certify that the above information is true and correct and is being submitted to Western Municipal Water District (District) to substantiate my claim to monies paid to the District. I further certify that I have the authority and right to claim and receive payment of these monies and hereby release the District, its directors, employees, representatives, attorneys, and agents from all liability and further obligation with respect to this claim.

*

I Agree

Please note: A Social Security Number or Federal ID Number will be required prior to processing payment to the claimant.