Form Ap-7 - Holder Reporting Errors

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HOLDER REPORTING ERRORS
AP- 7
For funds paid to the Department
TREASURY USE ONLY
Claim Number ________________________
Robert M. McCord
Date Received ________________________
Treasurer
Holder EIN ____________________________
Prepared By ___________________________
PART I HOLDER INFORMATION: (see instructions for claim completion)
EIN NUMBER
NAME OF HOLDER
STREET ADDRESS
CITY
STATE
ZIP CODE
CONTACT PERSON
TELEPHONE
EXT
PART II CLAIM INFORMATION:
TREASURY USE ONLY:
REPORT YEAR
Property ID Number__________________________________
PROPERTY CODE
ACCOUNT / REFERENCE NUMBER / CHECK NUMBER
IF IN AGGREGATE, SPECIFY AGGREGATE TOTAL
REPORTED OWNER(S) NAME (exactly as indicated on report)
REASON FOR ERROR
AMOUNT
NUMBER OF SHARES
TREASURY USE ONLY:
REPORT YEAR
Property ID Number__________________________________
PROPERTY CODE
ACCOUNT / REFERENCE NUMBER / CHECK NUMBER
IF IN AGGREGATE, SPECIFY AGGREGATE TOTAL
REPORTED OWNER(S) NAME (exactly as indicated on report)
REASON FOR ERROR
AMOUNT
NUMBER OF SHARES
PAGE 1 OF 3

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