VERIFIED CLAIM FORM
Date: ______________________ To: Wyoming Secretary of State's Office 200 West 24th Street, Suite 110 Cheyenne, WY 82002-0020 _______________________________________
(Name of entity)
Dear Secretary of State: The above entity is requesting a refund in the amount of $ Annual Report.
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