Form T-1 - Report Of Abandoned Property
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1The State of New Hampshire
TREASURY DEPARTMENT
ABANDONED PROPERTY DIVISION
25 CAPITOL STREET ROOM 205
CONCORD, NEW HAMPSHIRE 03301-6312
REPORT OF ABANDONED PROPERTY
FILE THIS COPY WITH YOUR TOTAL REMITTANCE ON NOV. 1 (MAY 1 FOR INSURERS)
STATE OF _______________________________
PAGE _____OF______
HOLDER:
COUNTY OF ____________________________:SS
I, _________________________, being first duly sworn, on oath depose and state that I
have caused to be prepared and have examined this report consisting of _________pages
as to property presumed abandoned under the New Hampshire Unclaimed and Abandoned
Property Law for the year ending as stated, that I believe that said report is true, correct
TAX ID#:
and complete as of said date, excepting for such property as has since ceased to be
STATE OF INCORPORATION:
abandoned.
:
CONTACT PERSON
Signature & Title_________________________________________________________
TELEPHONE NO/FAX NO:
__________________________________________________________
Notary
REPORT YEAR:
Subscribed and sworn to before me this _______day of ___________ 20_____._______
NUMBER OF INDIVIDUAL OWNERS LISTED ON THIS REPORT:___________
DATE OF LAST
AMOUNT
SHARES DUE
OWNER'S LAST NAME,FIRST NAME,
TRANSACTION OR
DUE OWNER
OWNER
PROPERTY IDENTIFYING
STREET ADDRESS, CITY, STATE, ZIP
DATE PROPERTY
BEFORE
(SEE INSTRUCTIONS)
AMOUNT
TYPE
ACCOUNT
OWNER SOC SEC. NUMBER
BECAME PAYABLE/
DEDUCTIONS &
CUSIP #
REMITTED AS
CODE
NUMBER
(LIST ALPHABETICALLY BY LAST NAME)
RETURNABLE
WITHHOLDINGS SHARES
TAX DATE
DUE OWNER
(1)
(2)
(3)
(4)
(5)
(6A)
(6B)
(7)
AGGREGATE AMOUNT
TOTAL
(IF THIS IS LAST PAGE OF REPORT, ENTER GRAND TOTAL)
MAKE CHECKS PAYABLE TO "TREASURER STATE OF NEW HAMPSHIRE"
NEW HAMPSHIRE
FORM T-1
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