Form Treas 400 - Holder Report Form - 2009
ADVERTISEMENT
1
22009
TREAS 400
HOLDER REPORT FORM
Remittance must accompany report
ALL SECTIONS MUST BE COMPLETED
1. HOLDER NAME & ADDRESS:
2. Below insert name or address changes
_____________________________________________
_____________________________________
_____________________________________________
_____________________________________
_____________________________________________
_____________________________________
_____________________________________________
_____________________________________
3. FEIN ______ ________________ Contact Person: ____________________ Tel. # _________________
4. State of Incorporation ______ Date of Inc. _____________ Fiscal year end _______________________
5. Total Assets ____________________ Annual sales/income _______________ # Employees __________
❍ Yes
❍ No
6. Does this report include all branches, divisions & subsidiaries?
7. If Company has changed its name or completed a merger, complete this section.
❍ Name change
From: ____________________________ To: ____________________________
❍ Merge
Primary: __________________________ Secondary: ______________________
INFORMATION ABOUT PROPERTY YOU ARE HOLDING
1. Total value of property placed in interest bearing accounts in 2009. . . . . . . . $ ________________________
DO NOT INCLUDE 1999 REPORTS (financial institutions only, see page 7)
2. Total number of unclaimed stock shares (list accts. on securities form) . . . . . . . __________________________
3. Number of unclaimed safe deposit boxes (list accts. on safe deposit form) . . . __________________________
4. Total value of accounts under $100.00 being remitted (reported as aggregate) . . . $ ________________________
5. Total value of accounts over $100.00 being remitted (list accts. on reverse) . . . $ ________________________
6. Total value of money remitted (total of lines 3 and 4) . . . . . . . . . . . . . . . . . . $ ________________________
Attach check & stock certificates to this holder report. Make check payable
to: Kentucky State Treasurer. DO NOT ATTACH SAFE DEPOSIT BOX
CONTENTS TO THIS REPORT.
Read page 17 before signing affidavit
VERIFICATION
I, _______________________________ , swear that I have prepared, or have caused to be prepared, and
have examined this report as to property presumed abandoned under KRS 393 and other applicable state laws.
I am duly authorized to execute this verification by the holder and by law. To the best of my knowledge and
belief, said report is true, correct, and complete.
E-MAIL ADDRESS ________________________________________________
Signature __________________________________ Title ___________________________ Date _________
OFFICE USE ONLY
Receipt # _______ HID # ________ Balanced ________
DO YOU NEED MORE TIME? (SEE PAGE 18)
9
KENTUCKY DEPARTMENT OF TREASURY
UNCLAIMED PROPERTY DIVISION
1050 US HWY. 127 S., SUITE 100, FRANKFORT, KY 40601
●
●
TOLL-FREE (800) 465-4722
FAX (502) 564-4200
e-mail: unclaimed.property@ky.gov
●
●
●
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial