Report Of Unclaimed Property Cover Sheet - Connecticut Unclaimed Property Division printable pdf download

Report Of Unclaimed Property Cover Sheet - Connecticut Unclaimed Property Division

TATE OF

ONNECTICUT

FFICE OF THE

TATE

REASURER

Unclaimed Property Division

Report of Unclaimed Property Cover Sheet

Calendar Year 20__

Holder Name_______________________________________ Tax ID Number ____________

Street Address_________________________________________________________________

City___________________________________ State______________ Zip Code_____________

State of Incorporation_____________________ Date of Incorporation____________________

Contact Name ____________________ Phone Number _______________E-mail_____________

FOLLOW INSTRUCTIONS FOR REPORTING UNCLAIMED PROPERTY

FILE ORIGINALS WITH YOUR REMITTANCE ON OR BEFORE MARCH 31

State of ___________________ County of ____________________

I, _______________________________, being first duly sworn, on oath depose and state that I have caused to

be prepared and have examined this report hereto totaling $ __________, # of shares ____________and # of

properties ______ as to property presumed abandoned under Connecticut Unclaimed Property Law for the year

ending as stated, that I am duly authorized to execute this verification by the holder and by law and that I

believe that said report is true, correct and complete as of said date, excepting for such property as has since

ceased to be abandoned.

Signature_________________________________ Title___________________________

Subscribed and sworn to before me this ____ day of ______________ 20__.

Notary Signature (and Seal)_______________________________________

Rev. 10/2009

Report Of Unclaimed Property Cover Sheet - Connecticut Unclaimed Property Division