claim request form

.
Reimbursement Claim Form
Whirlpool/Maytag merger tax reporting
Coy ID: WHRP
ACCOUNT INFORMATION
Holders Account Number:
C ________________________________________
(Located over bar code of your form 1099-B)
Account registration (Name on Account):
__________________________________________
Address (Line 1):
__________________________________________
Address (Line 2):
__________________________________________
City:
__________________________________________
State:
__________________________________________
Zip Code:
__________________________________________
Phone: (
) _______________________
E Mail: ________________________________________
‰
Reimbursement Amount: $
Signature of Account Holder (s):
__________________________________________
Reimbursement Claim instructions:
In order to claim this reimbursement, you must:
1.
Please provide Whirlpool account information above.
2.
Whirlpool will reimburse you up to $50.00 for any out-of-pocket expenses you incur in
preparing and filing an amended return to reflect your new 1099B.
3.
Provide a copy of the invoice from your tax filer of the amended return.
4.
Choose one of the below three methods to provide the request and backup documentation
1)
2)
3)
By Fax # 781-575-3601
By E Mail: Claims@Computershare.com
By Mail:
Computershare Claims Department
PO Box 43022
Providence RI 02940-3022
002CS14689
00QUFA