State of Washington Department of Revenue Unclaimed Property Claim Form PO Box 47477 # Olympia, WA 98504-7477 lin WA: (800) 435-2429 + Out-of-state: (360) 708-6706 # TTY: (360) 705-6718, KING 5 TELEVISION il i ine at: 1501 1ST AVES Ste 300 File Your Claim On-line at: = uep.dor.wa.gov SEATTLE WA 98134 5 VOID = Mail this form with the required proof to the address listed above, Pee Reported Account Information (Office Use Only) ee “A. Account Number (Infernal Use Only) 1234512345123451234512 B, Reported Owner 2. Claimant Mailing Address KING 5 TELEVISION © Reported Address 3. City State | 5. Zip Code 1501 1st AVE S Ste 300 SEATTLE WA 98134 6. Claimant Daytime or Message Phone / or E-mail Address C ) D. Description 7. Claimant Social See. No. or Federal Employer Id. No (FEIN) REBATE CHECK E, Amount TF. Year Reported to Washington '& Which statement best describes your relationship with the name Tisted in Box B? (check only one box) $75.00 2016 ser Penna ne G. Company Reporting Name listed isa Business Qi Power of Attorney VENDOR G Person is Deceased ~ your relationship Dorther Required Proof: (lditional instructions are on the back) 1. Photocopy of driver's license, passport, or other legal photo identification of all reported owners in Box B, and 2. Proof ofthe address listed above in Box C, see reverse side for examples (ifyou provide your driver’s license for #1 and it has the same address as Box C, no further proof is required). 3. Ifyour name has changed from what is listed on the claim, please provide proof of the name change. | affirm that the information provided is full, true, and correct. | agree to hold the state of Washington harmless against claim of all others for property which may be paid to me on the basis of my answers to these questions and the documentation provided. Caiman Signature) (lamas ma sign) : Vish our watt sien ae 7 a ce sien Dae REV a0 0006 17718)