Cloverleaf Local Schools Treasurer's Office 8525 Friendsville Road Lodi, OH 44254 (330) 721-3510

UNCLAIMED FUNDS FORM

Vendor Number (office use only): __________________________________________________

Date: ____________________

Employee or Vendor Name: ______________________________________________________

Address: _____________________________________________________________________

City: ___________________________ State: ________________ Zip: _________________

Check number(s): _____________ Date: ____________________ Amount: $____________

_____________

_____________

____________________

____________________

$___________

$___________

TOTAL	$___________

I found my name on the Unclaimed Funds link on the Cloverleaf Local Schools Treasurer’s Office webpage and I would like to claim my funds for the above check(s)!!

If you are an employee, you must have sent us a completed Authorized Agreement ACH Deposit of Reimbursements form. We no longer issue paper checks to employees for reimbursements. (This form is required even though you have direct deposit in payroll. Reimbursements are paidfrom atotally differentsystem from payroll and the two systems CANNOT exchange data. Also, some prefer that their reimbursements go to a different bank account than their payroll checks. Finally, the information required for ACH deposits is slightly different than what is required for payroll direct deposits. So you must complete this form even if you have payroll direct deposit.) You can access this formon the Treasurer’s webpage. We cannot release your
UNCLAIMED FUNDS without this form.

NAME (Please print legibly): ___________________________________________________________

Signature: ___________________________________________________________________________