Safe Deposit Box Report Template Indiana
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1INDIANA ATTORNEY GENERAL’S OFFICE
DIVISION OF UNCLAIMED PROPERTY
35 South Park Blvd.
Greenwood, IN 46143
SAFE DEPOSIT BOX REPORT
_________________________________
__________________________________
Reporting Institution
Report Year
BOX #_________________
DATE ABANDONED____________________
______________________________
______________________________________
Box Owner(s) Name
Social Security Number
________________________________________________________________________
Owner(s) last known address (street, city, state, zip)
Notice is hereby given that the undersigned intends to hold a lien against the
contents of the safe deposit box described above, escheated to the Indiana
Unclaimed Property Division in accordance with IC 32-34-1-29(g) in the amount of
$__________________.
______ Notice is hereby given that no lien exists against the contents of the safe
deposit box described above.
___________________________________
_________________________
Signature
Date
________________________
Title
Complete this form for each box reported and attach a detailed list of the box inventory.
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