Abandoned / Unclaimed Property Bond Request
Please note, you are in a secure area

Principal/Applicant Individual Corp Other

Name
Address     #        Street Name      St./Ave.
City/State/Zip
Social Security #
Phone
Fax
Email
Tax ID (if applicable)
Your Name, or Business Name
(as it appears on bond)

Amount
To Whom Bond is Payable
Address
City/State/Zip

1. You have thoroughly investigated this property and have determined
that you have a proper and valid claim to it.
Yes No
Explain:
2. You are the sole owner and no other party has an interest in this property
or any portion of this property.
Yes No
Explain:
3. You agree to hold the Surety harmless in the event another party claims
an interest in this property or a portion of this property.
Yes No
Explain:
A negative answer would generally cause this bond/applicant to be rejected.

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*On bonds over $50,000 please continue by filling out this Financial Statement below.
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Applicant is Married Single Separated
If married the financial statement is: Completed Jointly Not Completed Jointly
Individual Co-Partnership Corporation
Statement of Assets and Liabilities as of:
Month Year

* ASSETS * LIABILITIES
Cash Due to Banks (unsecured)
Stocks, bonds, etc Credit Cards
Accounts Receivable Taxes
Notes Receivable Accounts Payable
Vehicles Notes Payable
Equipment Due on Inventory
Home Due on Real Estate
Real Estate Other Liabilities
IRA Total Liabilities
Other Assets Net Worth
TOTAL ASSETS TOTAL LIAB. and NET WORTH

* Additional information may be required to verify balances over $10,000.

SOURCES OF INCOME FOR YEAR ENDED OTHER LIABILITIES

Salary, bonuses & commissions $ Do you have any contingent liabilities? No Yes
If Yes, explain
Dividends $
Real Estate Income $
Other income 1 $ Endorser, co-maker of guarantor? $
Other income 2 $ On Leases or contracts? $
Other income 3 $ Legal Claims (Judgments, etc) $
Other income 4 $ Other special debt $
TOTAL $ Amount of contested tax liens $

Are any assets owned by a trust?
No Yes
If Yes, describe
Ever declared bankrupt?
No Yes
If Yes, explain
Do you have a will?
No Yes   If Yes,
Name the executor
Are you a defendant in any suits or legal action?
No Yes
If Yes, explain
Are you a partner or officer in any other venture?
No Yes
If Yes, describe
Are any assets pledged?
No Yes
If Yes, explain
Any other obligations, alimony, child support, etc?
No Yes
If Yes, explain
Income tax paid through Year
Name your personal bank


By submitting information through this site, I authorize you and/or the surety to contact the individuals and companies given as references or other sources to gather information on the credit, character and capacity of the individuals and the company.
Name: Title: Date:
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or application containing any false, incomplete, or misleading information is guilty of a felony per state statute.

Press the Submit button below or you can fax or email to:
fax (561) 997-7087 or email to: bonds@beacongroupinc.com. or call 1-800 545-9007 ext. 133
Richard S. Wurst, ARM, AAI - License D048332 (Office use only)

 



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