Form Com 5523 - Unclaimed Funds Reporting Form - Ohio Division Of Unclaimed Funds - 2007

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Ted Strickland
STATE OF OHIO
DEPARTMENT OF COMMERCE
t
Governor
OHIO DIVISION OF UNCLAIMED FUNDS
Kimberly A. Zurz
77 S. High St., 20th Floor Columbus, OH 43215-6108, (614) 466-4433, FAX (614) 752-5078 Federal Tax ID# 31-1409347
Director
OUF-1 UNCLAIMED FUNDS REPORTING FORM
Apply Mailing Label Below Or Enter Current Information
Please Provide
Company Name
FEIN or SSN
Address
Contact Phone Number
City, State, Zip Code
Contact Email Address
Name of Contact Person
State of Incorporation
Contact Person Title
Year Incorporated
Report Year
Check box if changed from last filing date
2007
The Ohio Division of Unclaimed Funds encourages all companies filing a Negative (NONE) Report to file
their report on-line through the Ohio Business Gateway:
See pages 7-8 for registration and filing instructions.
The forms booklet is available at
Does the Company listed above have unclaimed funds to report?
If NO, sign the report Verification below and either mail your Negative
NO
Report to the address listed below or fax it to (614) 728-9769. Negative
Reports submitted without an FEIN and Signed Verification will not be
accepted.
If YES, complete the reverse side of Form OUF-1, sign the report Verifica-
YES
tion and mail your report, remittance check, securities and safe deposit
box contents to the address listed below.
Verification
Being first duly sworn the undersigned certifies they are the Holder or an Officer of the Holder or an Agent duly
authorized to sign this report and to the best of their knowledge and belief the foregoing report and supporting
records, is a true and complete report of all unclaimed funds required to be reported to the State of Ohio, inclusive of
interest and dividends thereon in accordance with Chapter 169 of the Revised Code, and the required notices have
been sent to owners and beneficiaries of record.
Signature
Title or Agent Relationship
Print Name
Date
MAIL THE REPORT, REMITTANCE CHECK, SECURITIES AND SAFE DEPOSIT BOX CONTENTS TO:
OHIO DIVISION OF UNCLAIMED FUNDS
77 SOUTH HIGH STREET, 20TH FLOOR
COLUMBUS, OHIO 43215-6108
COM 5523 revised 5/2004

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