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___ YES!  Please contact the state on my behalf.  Request that they search their records for my name and forward all responses directly to me.

Cost: $20.00*

Payment Method: Check or Money Order (please circle one)

*(includes correspondence and postage)  

Search Information: (please print or type)
Answering these questions correctly will help to expedite the inquiry process.

Who is this inquiry request for?               Yourself    /   Relative    /    Business

The information in the following chart pertains to the individual or business whom this inquiry request is for.

First Name or Business Name	:
Middle Name	:
Last Name	:
Maiden Name (if applicable)	:
Current Address? (Street)	:
City	:
State	:
Zip	:
Daytime Phone	:
Date of Birth	:
Social Security Number	:

 

Please answer the following questions applicable to the individual or business that
this inquiry request is for:

 

List the last 5 states that the individual or business this inquiry is for resided in.

City	:	State	:
City	:	State	:
City	:	State	:
City	:	State	:
City	:	State	:

 

 

If this inquiry request is for an individual other than yourself, or for a business,
please answer the following questions.

Your Last Name	:
First Name	:
Middle Name	:
Address:	:
City	:
State	:
Zip	:

Your relationship to the individual this inquiry request is for is:____________________

If this is for a business, what position do you or did you hold: _____________________

Mail or bring this Inquiry Service Form and your processing fee to:

Urban City
Unclaimed Money Inquiry Service
11617 West Montgomery Road
Houston, Texas 77086