Form Treas 400 - Unclaiimed Property Holder Report Form - 2013 Page 2

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OWNERS OF UNCLAIMED PROPERTY
COMMONWEALTH OF KENTUCKY
Date of
Name of owner, beneficiary,
Social Security
Amount
Amount Placed in
Account Number
Property
Last
surety, etc. (if applicable)
Code
or Federal Tax ID
Remitted
Interest Bearing
Certificate Number
[Last, First, Middle Initial]
Activity
Accounts in 2013
Policy Number
(See Page 22)
Number
Last Known Address
and/or Date of Birth
ONLY
Check Number
[Number & Street
City, State & Zip]
A computer printout with the required information is acceptable.
Page Total

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