Form B-Report Of Unclaimed Property
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1REPORT OF UNCLAIMED PROPERTY – FORM B
2. PAGE____ OF_____
ALL SECTIONS MUST BE COMPLETED
1. ________________________________________________________________
(Name of Business, Financial Institution, or Agency)
COLORADO DEPARTMENT OF TREASURY
3. PERIOD COVERED
LIFE INSURANCE
JAN 1 - DEC 31
ALL OTHER HOLDERS
JUL 1 - JUN 30
UNCLAIMED PROPERTY DIVISION
TO REPORT AND REMIT-COMPLETE ALL COLUMNS, MAIL
1580 LOGAN ST SUITE 500
WITH PAYMENT BY NOVEMBER 1 (ALL BUSINESSES
DENVER COLORADO 80203
EXCEPT LIFE INSURANCE COMPANIES WHICH MUST
REPORT AND REMIT BY MAY 1.) ATTACH CONFIRMATION
PHONE: (303) 866-6070 FAX: (303) 866-6154
OF SHARES, DRP, MUTUAL FUNDS TRANSFERRED INTO
TOLL FREE OUTSIDE DENVER METRO AREA (800) 825-2111
COLORADO & CO.
EMAIL: greatcopayback@state.co.us
9 DATE OF LAST
DEDUCTOIN CODE*
5. PROPERTY
6.
TRANSACTION OR
7 OWNER’S LAST NAME, FIRST NAME, MIDDLE INITIAL,
8. OWNER
10. AMOUNT
LESS (L) MORE(M)
12 TOTAL
4. PROPERTY
DESCRIPTION AND
INTEREST
DATE PROPERTY
STREET ADDRESS
SOCIAL SECURITY
REPORTED AS
AMOUNT
CODE
IDENTIFYING
EARNED
BECAME PAYABLE,
CITY, STATE ZIP
NUMBER OR FEIN
DUE OWNER.
11 A
11 B
REMITTED
NUMBER
X%
REDEEMABLE OR
CODE
AMOUNT
RETURNABLE.
0.00
0.00%
0.00
0.00%
0.00
0.00%
0.00
0.00%
0.00
0.00%
15. MAKE CHECK PAYABLE TO COLORADO DEPARTMENT OF THE TREASURY
$0.00
$0.00
13. TOTAL
16. MAIL CHECK AND COMPLETED FORMS TO ADDRESS SHOWN ABOVE
*DEDUCTION CODE - You may, by law, voluntarily deduct and retain from
14. (IF IS THE LAST PAGE OF THE REPORT, ENTER GRAND TOTAL)
each non-aggregate item remitted 2% or $25 of the value of the property you are
remitting whichever is less (L). For some types of property you may deduct and
Deductions may not be taken when reporting in the aggregate.
retain 2% or $25, whichever is more (M).
Form B Revised 8/06
THIS FORM MAY BE REPRODUCED
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