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STATE OF NORTH CAROLINA 3575608

DEPARTMENT OF STATE TREASURER
Unclaimed Property / Escheats Division
P.O. Box 20431, Raleigh, NC 27619-0431
Phone: (919) 508-1000

Janet Cowell
State Treasurer

A. Claimant(s) Name and Current Address: B. Original Owner(s) and Last Known Address:
JOYCE BRASWELL JOYCE B BRASWELL
848 NEW CASTLE COURT
CARY NC 27511 808 S FAYETTEVILLE ST

Social Security Number/Tax ID: CLAYTON NC 27520-2720

Daytime Phone Number: (252) 206-1176

C. Property Information

Property ID: 3073838

Holder Name: PRIMERICA LIFE INS CO
Property Type: OTHER AMTS DUE UNDER POLICY

D. Affidavit:

All claimants to the listed property must sign this claim form below before a notary and have signature(s) notarized. If the
claimant is a business entity, this claim must be executed by an officer of the business entity and must include evidence of the
officer's position and/or authority to act on behalf of the business entity.

The named claimant(s) hereby certifies that this property presumed abandoned is valid and just, that all statements are true
and correct, and that upon payment of this claim, said claimant will indemnify and hold harmless the State, its officers and
employees, from any other valid claims to said property or from any loss resulting from the payment of this claim. Any
person making a fraudulent claim will be subject to criminal prosecution.

State of ______________ County of ___________ Signature of Claimant(s)

Subscribed and sworn to before me this ___________________________________

________ day of _________________ , _______ ___________________________________

Notary Public _____________________________
___________________________________
State of ______________ County of ___________

My commission expires:______________________

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E - Instructions to Claimant(s)

1. Sign your name in Section D in the presence of a notary public and have claim form notarized.

2. Attach documentation to prove the address as shown in Section B under Original Owner. In addition, you MUST also
enclose proof of your complete social security number such as: a copy of your social security card, W-2 form,
insurance card, income tax form, bank statement or any document showing your social security number.

If the property you are claiming has stock or mutual fund shares, a Stock and Mutual Fund Instruction Letter will
print with your claim form and must be completed in order to process your claim. A completed W-9 is only required
if you wish to have your mutual funds re-instated. A W-9 is not required to liquidate mutual funds shares or in the
refunding of the stock. The Instruction Letter does not have to be notarized.

3. If you are claiming an account held in the name of a deceased owner, in addition to providing proof of the address as
shown in Section B, you will need to provide a copy of the death certificate and a current document from Clerk of
Court advising how property is to be dispersed. Such documents may include: Letters of Testamentary, Letters of
Administration, Small Estate Affidavit, Money Owed Decedent, etc. Estates previously closed may need to be re-
opened.

4. For business or organization accounts, you must provide proof of the address as shown in Section B - Original Owner.
You will need to provide a document showing the Federal Tax Identification Number for the entity for which you are
filing a claim.

5. Send completed form with all requested documentation attached to:

Department of State Treasurer

Unclaimed Property Program
P.O. Box 20431
Raleigh, North Carolina 27619-0431

Upon receipt of all required documentation, we will process your claim as quickly as possible.

6. If you have any questions, please call the Unclaimed Property staff at (919) 508-1000.

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