Form Treas 400(A) - Holder Report (Zero Report) - 2009
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12009
TREAS 400(A)
DISKETTE REPORTING IS NOT AVAILABLE
HOLDER REPORT FORM (ZERO REPORT)
By using this report form, I affirm that all records have been researched per KRS Chapter 393 and no
unclaimed property is reportable.
1. HOLDER NAME & ADDRESS:
2. Below insert name or address changes
Place label from back cover here
_____________________________________________
_____________________________________
_____________________________________________
_____________________________________
_____________________________________________
_____________________________________
_____________________________________________
_____________________________________
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: ______________________
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.
Signature _________________________________
Title _____________________________________
Date _____________________________________
DO YOU NEED MORE TIME? (SEE PAGE 18)
KENTUCKY DEPARTMENT OF TREASURY
UNCLAIMED PROPERTY DIVISION
1050 US HWY. 127 S., SUITE 100, FRANKFORT, KY 40601
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TOLL-FREE (800) 465-4722
FAX (502) 564-4200
e-mail: unclaimed.property@ky.gov
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