Claim Distribution Form for > in Liquidation

DEPARTMENT OF FINANCIAL SERVICES
Division of Rehabilitation and Liquidation
http://www.myfloridacfo.com/division/receiver/
For DFS purposes only;
______________Adjuster
______________date
______________Supervisor
______________date
Claimant Name Change Request - With or Without Address Change
(Non Assignments)
Company in Liquidation:
Claim #:
Policy #:
Receiver’s ID#/Suffix:
Claimant Name and Address currently on file with Receiver:
Name:
Address:
City:
State:
Zip:
Please enter the new information in the box below and attach the appropriate supporting documentation as
outlined in the instructions. A copy of a valid driver’s license, utility bill or passport reflecting the new information and
legal documentation to support the change(s) (marriage certificate, divorce decree, legal orders, death certificate,
corporate name change filing etc.) must be submitted.
Name:
Address:
City:
State:
Phone #:
Email:
Zip:
Please have your signature notarized below and return this form along with the supporting documentation to: The
Department of Financial Services, Division of Rehabilitation and Liquidation, Attention: Claims Dept. – Change
of Name/Address, 2020 Capital Circle SE Suite 310, Tallahassee, FL 32301.
I swear or affirm that I am the claimant referenced in the claimant name and address section of this form and/or am authorized to sign
this form on the claimant's behalf. I further swear under penalty of law that all information contained on this form as well as all
attachments are true and correct to the best of my knowledge.
____________________________________
_______________________________
Claimant Signature
Date
Relationship to Claimant
State of __________
County of ________
Sworn to and subscribed to me by _____________ on
this ____day of _______, 20___.
________________________
Notary Signature
Claimant Name Change Request Instructions (Non Assignment)
Depending on the reasons for your name change, you may need to also submit one or more of the following forms:
Divorce Affidavit
Name-Address Estate under 5000 Affidavit
Name-Address Inactive or Dissolved Company Affidavit
Name-Address Inactive or Dissolved Company Estate Affidavit
Support documents, as specified below, must accompany your request. All supporting documents must contain the
new information entered on the change form. The Receiver reserves the right to validate any name and/or address
change request received and may request additional information from you. Please contact us if you have questions by
clicking on the “Contact Us Form” in the website’s www.myfloridacfo.com/receiver navigation pane or you may call
Consumer Services at 800-882-3054.
A.
Name Change due to Marriage (with or without address change). Please complete the Claimant Name Change
Request Form With or Without Address Change and send it in with one of these documents:



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B.
Copy of valid driver’s license
Utility bill
Passport, or other photographic legal identity document
Copy of marriage certificate.
Name Change due to Death (with or without address change). Please complete the Claimant Name Change
Request Form With or Without Address Change and send it in with these documents:
 Copy of valid driver license or other photographic legal identity document for individual requesting name
change.
 Copy of death certificate.
 If the total amount of the claim is less than $5,000, a properly executed Name-Address Estate under
5000 Affidavit
 If the total amount of the claim is more than $5,000, a certified copy of court order identifying beneficiaries,
or documents from probate that reflect this information, copy of will and Petition for Discharge or
appointment of personal representative.
C.
Name Change due to Divorce (with or without address change). Please complete the Claimant Name Change
Request Form With or Without Address Change and send it in with one of these documents:
 Copy of valid driver license, utility bill, passport, or other photographic legal identity document.
 Copy of divorce agreement.
 A properly executed Divorce Affidavit
D.
Name Change for Active Companies or Corporations (with or without address change). Please complete the
Claimant Name Change Request Form With or Without Address Change and send it in with these documents:
 Copy of valid driver license or other photographic legal identity document for individual requesting name
change.
 If incorporated, copy of most recent filing with Sec of State (www.sunbiz.org), or filing that reflects name
change.
 If not listed with Sec of State submit signed statement by a listed officer authorizing payment, Corporate
bylaws reflecting authorization or Corporate resolution reflecting individual’s authority to act on behalf of
company.
E.
Name Change for Inactive or Dissolved Companies or Corporations (with or without address change). Please
complete the Claimant Name Change Request Form With or Without Address Change and send it in with
these documents:
 A copy of valid driver license or other photographic legal identity document for individual requesting name
change.
 Documentation that will clearly verify the connection between the individual and the dissolved company or
corporation, such as Tax Filings, occupational license, bank statements, etc.
 If incorporated, a copy of last filing with Sec of State (www.sunbiz.org) identifying officers.
 If not listed with Sec of State, submit signed statement by a listed officer authorizing payment or corporate
bylaws reflects authorization or corporate resolution authorizing Receiver to conduct a Bankruptcy Search
to confirm no creditors exist for dissolved company.
 A properly executed Name-Address Inactive or Dissolved Company Affidavit
 If owner deceased, a properly executed Name-Address Inactive or Dissolved Company Estate
Affidavit