Form Ac2709 - Verification And Checklist For Unclaimed Property
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2AC2709 (Rev. 10/13)
New York State Comptroller
OFFICE OF UNCLAIMED FUNDS
TH
110 State Street, 8
Floor
Albany, NY 12236-0001
VERIFICATION AND CHECKLIST FOR UNCLAIMED PROPERTY
Reporting Organization:
Verification for Period Ended
____________ , 20 __________
__________________________________________________
State of Incorporation
_______________________________
(name of business)
Date of Incorporation
_______________________________
__________________________________________________
Are You Authorized To Do Business in NYS?
____________
(area or department, e.g., Corp Trust Division)
FEDERAL EMPL ID NO:
______________________________
__________________________________________________
(street address)
Contact Person
______________________________________
__________________________________________________
Contact Title
______________________________________
(street address)
Contact Phone
(_____)________________________________
__________________________________________________
Contact Fax
(_____)________________________________
(city, state, zip code)
Address
______________________________________
__________________________________________________
______________________________________
(service bureau, if used)
______________________________________
__________________________________________________
______________________________________
(service bureau contact name)
Email Address
______________________________________
__________________________________________________
(service bureau contact phone)
I certify that I am a duly authorized officer of the above named organization. To the best of my knowledge and belief this report is a true and
complete statement of all abandoned property held by, or owing by, this organization as of the report period end date.
_____________________________________________
Signature
□
Payment Type: Electronic
Totals: Cash
_______________________________
□
Check
Issues
_______________________________
□
Securities
Shares
_______________________________
RESERVED FOR USE OF STATE COMPTROLLER
Amount Received
Date Received
Ack. Number
Media Type
Class
Report Sequence
Year
Comments
Be sure to complete the "checklist" sheet, indicating types and amounts of property being reported. Also, please verify that the property type(s) used on
this form are the same as the ones used in your detailed Report of Abandoned Property. Detailed instructions for completing this form are in the
Handbook for Reporters of Unclaimed Funds.
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