Form Vt Sto Upd 001 - Unclaimed Property Annual Compliance Report
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2Vermont State Treasurer's Office -- Unclaimed Property Division
109 State Street, Montpelier, Vermont 05609-6200 * Phone: 802-828-2407 * Fax: 802-828-2884
UNCLAIMED PROPERTY
ANNUAL
COMPLIANCE REPORT
(Cover Sheet Remittance MUST accompany report)
Form Completion HELP – Ref Page 26 & 27 of Holder Reporting Manual
HOLDER NAME
Submission Date:
:
MAY 1
20_
1/1/20 ______ to 12/31/20 ______
REPORT TIME PERIOD
REPORT DUE DATE
:
:
,
________
Federal ID Number:
Contact Person:
1. Address:
Email Address:
City:
Telephone:
State:
Zip:
State of Incorporation __________ Date of Incorporation: _____________________
Check Characteristic - Applicable to your Business
Total Assets
Premiums Written
Yearly Deposits
Sales/Gross Receipts
$ 0 – 10
$ 51 – 100
Check Range (Millions):
$ 11 - 25
$ 26 - 50
$ 101+
1 – 20
21 – 50
51 – 100
101 – 250
251 – 500
501 – 900
Employees:
901 +
2. Did you file a report of unclaimed property last year?
Yes
No
If “No”, please explain _______________________________________________________________________________________________________
2a. Did you file negative unclaimed property report last year?
Yes
No
3. Summary and classification of property reported/remitted on the following attached sheets:
Total
Accounts under $25
………………(______ # OF ACCOUNTS WITHIN AGGREGATE
a.
TOTAL)……
$_____________________
Accounts over $25 when owner’s name is unknown…………………………………………………………
b.
$ _____________________
Accounts over $25 when owner’s name is known …………………………………………………………...
c.
$ _____________________
):…..……………………… …
all accounts
TOTAL REMITTED (
$______________________
SAFE BOX - ESTIMATED
______________________
DELIVERY DATE
____________________________
d. SHARES REMITTED TOTAL
……………………………………………………………………………………….
Affidavit of Due Diligence
The undersigned, (print name) ____________________________________ declares that the Due Diligence mailing has been performed in
accordance with §1247 (g) V.S.A. Title 27, Chapter 14 on (indicate number of mailed letters) ____________________ accounts.
Name of Previous Holder: If you are a successor to a previous holder of the property, or if your have changed your name, please list such
prior holder:
Name________________________________________________ Address______________________________________________________
The undersigned, (print name) ________________________________, being duly sworn on oath, deposes and says that he/she has caused to
be prepared and has examined this report of _____ pages, totaling $_________, as to property presumed abandoned under the Vermont
Statutes Annotated, Title 27, Chapter 14, for the year ending as stated and that he/she, acting as duly authorized representative
of___________________________, declares, in accordance with Title 13, Chapter 67, Section 3016 ‘False Claims’, that, to the best of
his/her knowledge and belief, said report is a true and complete statement of all abandoned property held or owing by the HOLDER at the
close of business on this date, except such items as have since said date ceased to be abandoned.
Print Name: ________________________________ Signature ______________________________Title____________________________
Subscribed and sworn before me this _______ day of ____________________________, in the year of ________.
NOTARY:__________________________________________________________My commission expires:_________________________.
Make check payable and mail to:
Vermont State Treasurer's Office
th
109 State Street, 4
Floor, Montpelier VT 05609-6200
FOR UUNCLAIMED PROPERTY DEPARTMENT USE ONLY
Holder ID/Year/Suffix
Check Amount
Deposit Date
Balanced By
HOLDER LABEL
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