Kansas
summary of unclaimed property
Must be postmarked on or before November 1st (May 1st for Life Insurance)
Business Name____________________________________________________________________
Business information
900 SW Jackson St. Ste 201
Topeka, KS 66612-1235
(785)291-3173
Tax ID #___________________________________________ Incorporated In______________
(785)291-3172 fax
State
Business Address____________________________________________________ ________________________ ________ ______________
Mailing Address
City
State
Zip
Previous Business Name(s)__________________________________________________________________________________________
(If Applicable)
contact information
____________________________________________________ ______________________________ _____________________________________
This person will be listed as the contact for property inquires (required)
Name
Phone
Email
report information
Report Total Dollar Amount $____________________________
Check if filing a Zero Report
(not required in KS)
*
Report Method
Paper*
NAUPA CD/Disk
UP3 Online System
Secure Upload
*
*
*
*
Payment Method
Check
ACH/Wire
Check/ Wire or ACH#____________________________
*
*
Reporting Safe Deposit Boxes
YES
Number of Boxes Reported______________________
*
Reporting Shares of Stock
YES
Number of Shares Reported**___________________
*
*Paper Reports are only accepted for reports 25 properties & under and must use our form (page11). If you have a Naupa paper report,
a disk must be submitted or upload your Naupa file to our secure site at .
**Supply Confirmation Statements with report.
Securities must be remitted according to the instructions on website:
(Click on .PDF link at bottom of web page)
Check Paybable To:
Kansas State Treasurer
Mail Report To: Kansas Unclaimed Property Dept
Holder Services
ACH/Wire Info:
Contact our Office
900 Sw Jackson St Ste 201
lisa@treasurer.ks.gov
Topeka, KS 66612-1235
I swear that I have prepared, or have caused to be prepared, and have examined this report as to property presumed
tttttttttttttttttttttttttttttttttttttttttttttttttttttttttttt
abandoned under the Uniform Unclaimed Property Act. I am duly authorized to execute this verification by the
holder and by law. To the best of my knowledge and belief said report is true, correct and complete.
________________________________________________________
__________________
______________________________________
Signature
Date
Phone Number
________________________________________________________
_____________________________________________________________
Print Name
Email Address
10