Holder Report Cover Sheet - Connecticut Treasurer'S Office

Holder Report Cover Sheet - Connecticut Treasurer'S Office - 2010

TATE OF

ONNECTICUT

FFICE OF THE

TATE

REASURER

Unclaimed Property Division

HOLDER REPORT COVER SHEET

Calendar Year Ending December 31, 2010

Holder Name_______________________________________ Federal 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, under 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 above, that I am duly authorized to execute this verification on behalf of the holder and I

believe that said report is true, correct and complete as of said date.

Signature_________________________________ Title___________________________

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

Notary Signature (and Seal)_______________________________________

Rev. 2-16-2011

Holder Report Cover Sheet - Connecticut Treasurer'S Office - 2010