Annual Report Of Abandoned Safe Deposit Box Property Template
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1ANNUAL REPORT OF ABANDONED SAFE DEPOSIT BOX PROPERTY
This report must reach us on or before the due date, and must be signed by a current
office or partner. The filing deadline is November 1 of each year for the preceding year
ending June 30 (IC 32-34-1 et. seq.).
A Detailed Inventory of Safe Deposit Box Contents Must be Attached.
____________________________________________________________________________________________
Holder Name
____________________________________________________________________________________________
Holder Address (Street, city, state, zip)
____________________________________________________________________________________________
Contact Name and phone number
_____________________________________________
____________________________________________
Contact E-mail Address
Federal Employer Identification Number
Please list all prior business names (if merged or acquired by another business).
___________________________________________________________________________________________
BUSINESS CLASSIFICATION (Check One)
REPORT FOR YEAR ENDING: ______________
____ National Bank & Trust Co.
____ State Bank & Trust Co.
SUMMARY OF PROPERTY
____ Savings (or Bldg.) & Loan Assoc.
____ Credit Union
Total number of boxes delivered.
____ Corporation (other than above)
____ Other __________________________
________________________________________
VERIFICATION
I hereby verify, under penalties or perjury, that the facts contained herein are true and I am duly authorized to
execute this verification by the holder and by law.
__________________________________________
________________________________________
Signature of Current Officer
Title
__________________________________________
(
)
_
Extension ________
Printed Name
Phone Number
INDIANA ATTORNEY GENERAL’S OFFICE
Return Completed Form to:
Division of Unclaimed Property
35 South Park Blvd
Greenwood, IN 46143
317-883-4520
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