Unclaimed Property Owners Currency

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I
___ _
This form can only be used by entities reporting
U NC LAI MED PROPERTY OWNERS
five or fewer property records.
MINNESOTA
DEPARTMENT
OF
COMMERCE
A. HOLDER NAME
C. MN HOLDER ID#
D. REPORT YEAR
E. PAGE
OF
B. TAXID#
#
I.
Owner Name
2.
Last Known Address
3. Social Security
4.
Property
S.
Date of
6. Account
7. Amount
8.
Deductions &
9. Amount
#
With holdings
Remitted
[Last, first, Middle Initial]
[Street, City, State, Zip]
or federal Tax
Code
Last
Certificate
Reported
#
ID Number
Activity
Policy
Type
Amount
$
A computer printout with the above-noted information is acceptable
I 0. Total remitted for this page:
UP-C 000800

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