Holder Report Cover Sheet - Affidavit Of Due Diligence (Hawaii)
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1____________
HOLDER CODE:
Holder Report Cover Sheet
Affidavit of Due Diligence
+
use
For Official
ONLY
TDR Date:
tAll Holders Except Life Insurers
Reporting Period July 1 through June 30
Amount $:
Unclaimed Property Program
+ Life Insurance Companies
Shares:
Bo' 150
honolulu. Iii 96810
`Ii.
4
Reporting Period January 1 through December31
Office location:
2511
lotci
* Itcx,ni
Import #:
I
Street
3114
.
I tl'ntIIuIu, Ill 96513
808586-1589
Input Initials:
This transmittal mustaccompany all holder reports.
REPORT YEAR
COMPLETE FORM: PRINT OR TYPE, NOTARIZE
General Information
Holder Name:
Federal Identification Number:
Mailing Address:
State of Incorporation:
Date of Incorporation:
City:
State:
Zipcode:
Name of contact person or department designated to respond to unclaimed property inquiries:
Name:
Telephone number:
efl:
E-mail address:
your
company file an unclaimed property report last year with
Hawaii?
Did
NO
YES
If "YES",
and you filed under a different name, address or Federal
ID#, complete the
information
below:
Previous Holder Name:
Federal Identification Number
Mailing Address:
State of Incorporation:
City:
State:
Date of Incorporation:
Zipcode:
Reporting Requirements
C
C
$
This report includes interest-bearing properties.
YES
NO
Report Total
Total Remittance$
* Remittance payable to: Director of Finance, State of Hawaii
Total Shares
undersigned.
Jeclares. under penalty or perjury,
`ttKlr ICA I
At'.LJ
I II.IAVI I:
Ilie
IUI'i
Al'
that, to the best of his/her knowledge, the foregoing report ana supporting recoras,
contain a run. true and complete report of unclaimed
in the possession or under the control of the holder, which is presumed abandoned in accordance viIh the provisions of the
property
no'
*Interesthearing properties are c/early denoted.
Hawaii Revised Statutes
523A. Note:
Chapter
I have attempted to contact owners of property valued at $50
their last known
er more at
mouths before filing the rei
-t. I am du
authorized to attest to this.
Title
Signature
Date
State of:
day of
to
me this
Subscribed and sworn
before
,20
Nolan
Stamp
-
Notary Public
Commission Expires
rev. 9/1 5111
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