Form A - Report Of Unclaimed Property
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1REPORT OF UNCLAIMED PROPERTY – FORM A
COLORADO DEPARTMENT OF TREASURY
UNCLAIMED PROPERTY DIVISION
1580 LOGAN ST SUITE 500
DENVER, COLORADO 80203
303-866-6070 OR TOLL FREE 800-825-2111
FAX: 303-866-6154
WHO IS REQUIRED TO REPORT?
•
All types of companies and business entities (legally referred to as business associations), except racetracks;
•
Public institutions including courts, municipalities, governmental subdivisions/agencies, public corporations or authorities;
•
Non-profit entities, hospitals, utilities, estates, or any other legal or commercial entity.
This form must be filed in accordance with the Unclaimed Property Act, Title 38, Article 13 of the Colorado Revised Statutes.
ALL SECTIONS MUST BE COMPLETED.
1.
Name of Business (Holder):
Street Address and Mailing Address:
City, State Zip:
-
-
2.
ENTER YOUR FEDERAL EMPLOYER’S TAX IDENTIFICATION NUMBER (FEIN)
3.
State of Incorporation
Date of Incorporation
or Principal Place of Business
or Date Business Started
4.
Total Assets
Less than $500,000
$500,000 to $5 Million
$5 Million to $100 Million
More than $100 Million
Annual Gross Income
Less than $500,000
$500,000 to $5 Million
$5 Million to $100 Million
More than $100 Million
5.
Please indicate which of the following best describes the primary activity of your company (check one):
Banking/Trust (10)
Government (70)
Mutual Funds (38)
Services (52)
Churches (66)
Health Care Facilities (67)
Oil & Gas (55)
Transportation (54)
Construction (51)
Insurance, Life (30)
Retail (50)
Utilities/Cable Co. (75)
Credit Union (20)
Insurance, Other (35)
Savings & Loan (15)
Other specify below (45)
Finance/Investment (40)
Manufacturing (53)
Schools, Colleges, Univ. (60)
6.
If you have reported previously under a different name or Federal Employer’s Tax ID number (FEIN), please list below:
PREVIOUS HOLDER NAME
DATE OF CHANGE
PREVIOUS FEIN
-
-
7. a.
Contact Person for Reporting
Contact Person for Claims
Telephone Number
Telephone Number
FAX
FAX
Email
Email
Mailing Address (if different from above)
Mailing Address (if different from above)
8.
If you have reported Colorado unclaimed property to another state, please indicate the name of the state:
9.
The following must be completed and signed by a duly authorized officer of the company:
I, ________________________________, affirm and state that I have caused to be prepared and have examined this report of _____ pages (including
this form) as to property presumed abandoned under the Colorado Unclaimed Property act (CRS 38-13-101, et seq) for the year ending as stated, that I
am duly authorized to attest that I believe that said report is true, correct and complete as of said date, excepting for such property as has since ceased to
be abandoned.
Total dollar amount remitted
Total shares remitted
Date:
By check
By electronic funds transfer
Signature of Officer
Title
Phone:
10.
Make checks payable to:
Colorado Department of the Treasury.
Attach payment with this form and mail to the address above. Attach confirmation of shares, stock and mutual funds transferred into Colorado & CO.
Form A 0503.doc rev 07/03
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