Unclaimed Property Owner Detail Report Form - Office Of The State Treasurer Kansas
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Unclaimed Property Owner Detail Report
Office of the State Treasurer
Page _____ of ______
Lynn Jenkins, CPA
Business Name _______________________________________________________
Unclaimed Property
900 SW Jackson St Ste 201
Fed. Emp. I.D.#________________________________ Report Year_____________
Topeka, Ks 66612-1235
Relationship Code is required for all properties with 2 or more owners. If the code is not included with the report, a staff
member from our office will call and request a relationship code (see relationship codes page 11).
List owner names(s) exactly as they appear on your records
1
Last Transaction Date
Property
Amount
Reference No.
Code
Remitted
(Account/Cert. No.)
_____/_____/_____
Owner Name 1 (Last First & Middle Name)
Social Security No.
(See Table
(Title)
OR
$
page10-11)
Periodic Payments
From
Social Security No.
Owner Name 2 (Last First & Middle Name)
(Title)
For Securities
_____/_____/_____
Remitted Also
Relation
Complete Page 15.
Mailing Address
To
_____/_____/_____
-
City
State
Zip Code
Shrs
2
Property
Amount
Reference No.
Last Transaction Date
Code
Remitted
(Account/Cert. No.)
_____/_____/_____
Owner Name 1 (Last First & Middle Name)
Social Security No.
(Title)
(See Table
OR
page10-11)
$
Periodic Payments
From
Owner Name 2 (Last First & Middle Name)
(Title)
Social Security No.
For Securities
_____/_____/_____
Remitted Also
Complete Page 15.
Relation
Code
Mailing Address
To
_____/_____/_____
-
City
State
Zip Code
Shrs
3
Last Transaction Date
Property
Amount
Reference No.
Remitted
Code
(Account/Cert. No.)
_____/_____/_____
Owner Name 1 (Last First & Middle Name)
Social Security No.
(See Table
(Title)
OR
$
page10-11)
Periodic Payments
From
Social Security No.
Owner Name 2 (Last First & Middle Name)
(Title)
For Securities
_____/_____/_____
Remitted Also
Relation
Complete Page 15.
Code
Mailing Address
Securities Remitted
To
Complete page
_____/_____/_____
-
City
State
Zip Code
Shrs
4
Last Transaction Date
Property
Amount
Reference No.
Code
Remitted
(Account/Cert. No.)
_____/_____/_____
Owner Name 1 (Last First & Middle Name)
Social Security No.
(Title)
OR
(See Table
page10-11)
$
Periodic Payments
From
Owner Name 2 (Last First & Middle Name)
(Title)
Social Security No.
For Securities
_____/_____/_____
Remitted Also
Relation
Complete Page 15.
Code
Mailing Address
To
_____/_____/_____
-
City
State
Zip Code
Shrs
This form must be completed and filed with the Summary of Unclaimed Property form on page 12.
Page Total $
This form may be duplicated for additional
Accumulated Page Total $
properties.
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