Report Of Unclaimed Property Form - Rhode Island

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State of Rhode Island and Providence Plantations
Treasury Department
Unclaimed Property Division
PO Box 1435
Providence, RI 02901-1435
REPORT OF UNCLAIMED PROPERTY
Report Year 20___
HOLDER INFORMATION
___________________________________
___________________ __________________
(Name of Holder)
(Federal Tax ID #)
(SIC Code)
___________________________________
___________________
_____ __________
(Street Address)
(City)
(St)
(Zip)
______________________
________________________
______________________
(Holder Type Code)
(State of Incorporation)
(Date of Incorporation)
List the names and last known address of all previous holders of the property if you are a successor.
If you have changed your name during the time
period in which you have held the property, list the prior names(s).
__________________________________________ __________________________
(Previous Holder)
(Date of Change)
_________________________________
____________________
____
____________
(Street Address)
(City)
(St)
(Zip)
_________________________________
_____________________
_________________
(Contact Person)
(Telephone)
(Fax)
_________________________________
__________________
____
______________
(Street Address)
(City)
(St)
(Zip)
State of __________________________
County of ____________________________
I, _________________________________, being first duly sworn, on oath depose and
state that I have caused o be prepared and have examined this report consisting of _____
pages totaling $______________ as to property presumed abandoned under the Rhode Island
Unclaimed Property Law for the year ending as stated; that I am duly authorized by the
holder herein to execute this report; and I believe that said report is true, correct and
complete as of said date.
Signature ____________________________________
Title ____________________________________
Subscribed and sworn to before me this ________ day of ______________________, 20____
Notary ____________________________________
Commission Expires
___________________________________
NOTE
The verification, if made by a partnership, shall be executed by a partner; if made by an unincorporated association or private corporation, by
an officer; and if made by a public corporation, by its chief fiscal officer.
________________________________________________________________________________
Treasury Use only
___________________________________________________________________________
Report compliance
____
________________
Received Date _________________
Holder added/updated
____
________________
Voucher# _________________
Owner records added
____
________________
Vo. Date _________________
Verification/Lock
____
________________
Stock Rec. _________________
Rpt Total
$______________
Cert # _________________
Non-Agg Tot $______________
Shares # _________________
Agg Total
$______________

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