Form Ucp-135 - Holder Request For 60 Day Extension Of Due Date For Holder Report
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Holder Request for 60 Day Extension of Due Date for Holder Report
Section 1 – Holder Information
Holder name
FEIN
Street Address
Reporting Month & Year
City
State
Zip
Contact Phone Number
(
)
Contact Person
Contact Fax Number
(
)
Estimated / Actual Dollars to be Reported / Remitted
Estimated / Actual Shares to be Reported / Remitted
Section 2 – Request for Information
Reason for Extension
(see instructions below)
Print Name
Title
Signature
Date
Instructions
Required information:
• Under Reason for Extension, provide a detailed explanation of why you are requesting the extension.
• Submit this form at least 30 days prior to the original filing due date. For example, if your report was originally due
November 1, you must complete this form and mail, fax or email it no later than October 2.
Mail to:
Wisconsin Department of Revenue
PO Box 8982
Contact information:
Madison WI 53708-8982
608-264-4594
Website:
Fax to:
608-261-6799
Email to:
DORWIHolderReports@revenue.wi.gov
UCP-135 (R. 7-15)
Unclaimed Property • Wisconsin Department of Revenue
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