Free Verified Claim Form - Wyoming

VERIFIED CLAIM FORM
Date: ______________________ To: Wyoming Secretary of State's Office 200 West 24th Street, Suite 110 Cheyenne, WY 82002-0020 _______________________________________
(Name of entity)

Re:

Dear Secretary of State: The above entity is requesting a refund in the amount of $ Annual Report.
(year)

for the
(dollar amount)

The reason for requesting the refund is as follows:

Signature: _________________________________ Title: _____________________________________

State of Wyoming County of ______________________________ The foregoing instrument was acknowledged before me by __________________________________, this _______ day of _________________ , ______. Witness my hand and official seal. ____________________________ Notary Public SEAL