S
C
TATE OF
ONNECTICUT
O
S
T
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
st
.
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