Dormant Account Funds Claim Form

1
BANK OF GHANA
FINANCIAL STABILITY DEPARTMENT
DORMANT ACCOUNT FUNDS CLAIM FORM
Part A: Claimant Information
This section should be completed by the person(s) making the claim (either the dormant account holder or the legal representative). By providing the following information, you mandate the Bank of Ghana and the reporting institution to carry out independent validation of the information. Are you the Account Holder? YES NO

1. First Name 2. Middle Name 3. Surname
2. Address: 5. Telephone No.
3. Relationship with Dormant Account Holder (e.g. Executor, Mother, Father, Son, etc.) 7. National ID No.
4. Evidence provided for Relationship (tick if applicable) 9. Email Address
   Probate/LA Other Legal Instrument. Power of Attorney
5. Which of the following documentary evidence do you have in respect of the account (tick applicable)
   Passbook Bank Statement Letters Publication Other: …………………………….
6. Reason for making the Claim: (tick if applicable)
   Account Holder Deceased Account Holder Incapacitated Others: ……………………………..
7. Claimant Signature: 12. Date:
   Part B: Dormant Account Holder Information
   Provide the following information about the dormant account holder
8. Account Name: 14. Account Number:
9. Name of Bank/SDI: 16. Branch:
   PUBLIC

NB: A validated claim would be paid by the Bank of Ghana into the clearing account of the Bank/SDI that 2 originally submitted the funds to the Bank of Ghana
17. ID Type/Number/Buss Reg. No. 18. Date of Birth:
19. Address: 20. Telephone No.
21. Claim Amount
Currency Amount
GHS
USD
GBP
EUR
Other (Specify)
Part C: Validation by Bank/SDI
This section is to be provided by the bank/SDI presenting the claim on behalf of the dormant account holder or claimant.

1. Name of Bank Representative : Position:
   Signature Date:
2. Name of Bank Representative : Position:
   Signature and Stamp Date
   This form should be submitted by the Bank/SDI with all supporting documents on behalf of the claimant/dormant account holder within five (5) working days after receipt of the claim to:
   The Head
   Financial Stability Department
   Bank of Ghana
   We confirm that the above information provided by the claimant/account holder has been validated as per the account information available to the bank/SDI and supporting documents. PUBLIC