Report Form 1 - Unclaimed Property Division - Alabama Department Of Treasury Page 2
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3REPORT FORM 2
This form or computer printout containing all requested information must be completed and filed with Report Form 1
K
I
AY
VEY
PAGE_____ of _____
Fed. Emp. I. D. No.
Business Name______________________________________________________
S
T
TATE
REASURER
Report Year
Address____________________________________________________________
U
P
D
NCLAIMED
ROPERTY
IVISION
City_____________________________________ State__________ Zip_________
•
P. O. Box 302520
Montgomery, AL 36130-2520
Contact Person __________________________________ Phone No. __________
(334) 242-9614
1-888-844-8400
Period Covered From______/______/______ to ______/______/______
THIS FORM PROVIDES SPACE FOR REPORTING THREE ACCOUNTS.
Unclaimed Property Report
All items under $10.00, excluding dividends, can be combined (See instructions)
If Reporting Securities
List owner names(s) exactly as they appear on your records
Property Must Be Described Below
Property
Total Amount
Certificate or
1
Issue Name
Shares
CUSIP
Delivery
or use property codes (page 14)
Type
Remitted
Account Number
Date of Last Transaction
________________________________ ________________
____/____/____
__________________________
LAST NAME
FIRST NAME
______
______________ __________________ _______________
OR
__________________________
Cash
PERIODIC
MIDDLE NAME
TITLE
SOCIAL SECURITY NO.
PAYMENTS
__________________________
______
_________________________________________________
Sec.
$________________.____
From:
MAILING ADDRESS
__________________________
____/____/____
______
_________________________________________________
__________________________
Other
To:
____/____/____
____________________ _____ _________ _______-____
__________________________
CITY
STATE
COUNTY
ZIP CODE
List owner names(s) exactly as they appear on your records
Property Must Be Described Below
2
or use property codes (page 14)
Date of Last Transaction
________________________________ ________________
____/____/____
__________________________
LAST NAME
FIRST NAME
______
______________ __________________ _______________
OR
__________________________
Cash
PERIODIC
MIDDLE NAME
TITLE
SOCIAL SECURITY NO.
PAYMENTS
__________________________
______
_________________________________________________
Sec.
$________________.____
From:
MAILING ADDRESS
__________________________
____/____/____
______
_________________________________________________
__________________________
Other
To:
____/____/____
____________________ _____ _________ _______-____
__________________________
CITY
STATE
COUNTY
ZIP CODE
3
List owner names(s) exactly as they appear on your records
Property Must Be Described Below
or use property codes (page 14)
Date of Last Transaction
________________________________ ________________
____/____/____
__________________________
LAST NAME
FIRST NAME
______
______________ __________________ _______________
OR
__________________________
Cash
PERIODIC
MIDDLE NAME
TITLE
SOCIAL SECURITY NO.
PAYMENTS
__________________________
______
_________________________________________________
Sec.
$________________.____
From:
MAILING ADDRESS
__________________________
____/____/____
______
_________________________________________________
__________________________
Other
To:
____/____/____
____________________ _____ _________ _______-____
__________________________
CITY
STATE
COUNTY
ZIP CODE
PAGE TOTAL $_____________
ACCUMULATED TOTAL $_____________
This form may be duplicated for additional owners.
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