The State of Texas

THE STATE OF TEXAS § § THE COUNTY OF BEXAR §

AFFIDAVIT REGARDING UNCLAIMED PROPERTY AND OUTSTANDING CHECKS

BEFORE ME, the undersigned authority, on this day personally appeared ______, known to me to be the person whose name is subscribed to this instrument, and who, being by me first duly sworn, did depose and state as follows:

1. My name is ______. I am above the age of 18 years, have never been convicted of a felony, and competent to testify to the matters set forth below. All of these matters are within my personal knowledge and are known to me to be true and correct.

2. I am the owner of that (those) certain item(s) of personal property that is (are) described with specificity in the attached Exhibit 1 (“Property”). The Property is currently being held by the City of San Antonio, Texas (“City”) as either unclaimed property or an outstanding check.

I am the (check one) ___natural parent ___managing conservator ___ guardian of the estate ___ attorney in fact of ______, the owner of that (those) certain item(s) of personal property that is (are) described with specificity in the attached Exhibit 1 (“Property”). The Property is currently being held by the City of San Antonio, Texas (“City”) as either unclaimed property or an outstanding check.

I am the (check one) __ executor ___ administrator of the estate of ______, Deceased, who during his/her lifetime was the owner of that (those) certain item(s) of personal property that is (are) described with specificity in the attached Exhibit 1 (“Property”). The Property is currently being held by the City of San Antonio, Texas (“City”) as either unclaimed property or an outstanding check.

Attached as Exhibit 2 is a true and correct copy of the document(s) that confer the authority specified above upon me, such as a Birth Certificate; a Divorce Decree; Letters of Guardianship; a Power of Attorney; Letters Testamentary; or Letters of Administration, respectively.

1 3. ____ Check if applicable (For Owner) A true and correct copy of my Driver’s License is attached as Exhibit 3.

____ Check if applicable (For natural parent, managing conservator, guardian of the estate, or attorney in fact) A true and correct copy of the Driver’s License of the person described in (2) above is attached as Exhibit 3.

_____ Check if not applicable because owner is an Entity.

4. My Social Security Number is ______.

The Social Security Number of the person or the Tax Identification Number of the Entity described in (2) above is ______.

5. My address is:

______.

6. My telephone number is: ______

7. My e-mail address is: ______

8. I am claiming the Property for myself or on behalf of the person or entity named in (2) above.

9. I request and authorize the City to forward the Property to my attention at the address set forth in (5) above.

10. For and in consideration of the City forwarding the Property to my attention, I hereby, for myself, and, if applicable, on behalf of the person or entity named in (2) above, release the City from any and all claims,

2 liabilities, obligations, or duties that are directly or indirectly related to the Property. For the same consideration, I hereby indemnify and hold the City harmless from and against any claims, liabilities, expenses, costs, fees or charges of any type whatsoever that are asserted against the City by any person or entity whatsoever and are directly or indirectly related to the City forwarding the Property to my attention.

11. FURTHER, AFFIANT SAYETH NOT.

______AFFIANT

______AFFIANT’S PRINTED NAME

SUBSCRIBED AND SWORN TO before me, the undersigned Notary Public in and for the State of Texas, by the said______, this _____ day of______, 20__.

______Notary Public, State of Texas

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