Form Ador 17 - Unclaimed Property Report

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Arizona Department of Revenue • Unclaimed Property Section
UNCLAIMED PROPERTY REPORT
(Remittance must accompany report)
Please check one:
Life Insurance Annual Report
Annual Report (all other entities)
Date:
Federal ID Number:
Contact Person:
1. Entity Name:
Telephone: (
)
Address:
State of Incorporation (if incorporated):
City:
State:
Zip:
Date of Incorporation (if incorporated):
Sales/Gross Receipts (millions):
$0 - 10
$11 - 25
$26 - 50
$51 - 100
$101+
Employees:
1 - 20
21 - 50
51- 100
101 - 250
251 - 500
501 - 900
901+
2. Did you file a report of abandoned property last year?
Yes
No
If "No", please explain
3.
North American Industry Classification System (NAICS), 6 digits: ___ ___ ___ ___ ___ ___
4.
Summary and classification of property reported/remitted on the following attached sheets (i.e. wages, vendor checks, etc.):
a.
Accounts under $50 ........................................................................................................................... $
b.
Accounts $50 and over when owner's name is unknown (attach detailed Schedule A) ....................
$
c.
Accounts $50 and over when owner's name is known (attach detailed Schedule A) ........................
$
Total Remitted (all accounts): ............................................................................................................. $
Shares of Stock: Issue
CUSIP No.
Number Shares
Sent DTC:
Yes
No If "Yes", enclose confirmation.
Number of Safe Deposit Boxes Remitted: ___________________
Name of Previous Holder: If you are a successor to a previous holder of the property, or if you have changed your name, please
list such prior names below:
Name
Address
The undersigned declares under penalty of perjury, that to the best of his/her knowledge and belief, the foregoing information and the information
set forth in the schedules attached is true and correct.
Print Name
Signature
Title
Make check payable and mail to: Arizona Department of Revenue Unclaimed Property
1600 West Monroe Street, Phoenix, AZ, 85007
FOR DEPARTMENT USE ONLY
Reference No.
Check Amount
Deposit Date
Balanced By
ADOR 17-2006 (9/06)

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