Report Of Unclaimed Safe Deposit Box Contents - 2010
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12010
REPORT OF UNCLAIMED SAFE DEPOSIT BOX CONTENTS
PACKAGES CONTAINING WEAPONS MUST BE CLEARLY IDENTIFIED
For Department Use Only
(INITIALS)
A
Holder Name: ____________________________________________
❍ Accept
________
________
❍ Reject
________
________
B
Tax ID Number: __________________________________________
Allowed Amounts
C
Period Covered: ________ to _______
D
Page ______ of _______
❍ Rental Charges
________
________
❍ Drilling Fees
________
________
DO NOT ATTACH TO CONTENTS
E
One Safe Deposit Box Per Page
1
Safe Deposit Box Number
5
Date of Abandonment (Month, Day, Year)
2
Owner Information
6
Branch Where Property Was Held
_________________________________________________________________________
Branch Name
Phone #
Last
First
Middle
_________________________________________________________________________
Street or PO Box
3
Social Security Number
D.O.B.
_________________________________________________________________________
City
State
Zip
4
Owner’s Mailing Address
7
Amount Due Holder
Type
Amount
Drilling . . . . . . . . . . . . . . . . . . . . $ ___________________________
Street or PO Box
Unpaid Rent . . . . . . . . . . . . . . . . $ ___________________________
Other . . . . . . . . . . . . . . . . . . . . . $ ___________________________
City
State
Zip Code
Total
$
Must show proof of expenditures.
8
Itemized Description of Contents (One Item Per Line or Attached Itemized List)
1. __________________________________________________ 7. __________________________________________________
2. __________________________________________________ 8. __________________________________________________
3. __________________________________________________ 9. __________________________________________________
4. __________________________________________________ 10. _________________________________________________
5. __________________________________________________ 11. _________________________________________________
6. __________________________________________________ 12. _________________________________________________
Do not use form if reporting over 10 owners-report on diskette. Note: Report contents by diskette.
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