Safe Deposit Box Inventory Form - State Controller'S Office
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SAFE DEPOSIT BOX INVENTORY FORM
Section I
Safe Deposit Box #:
Lien Amount:
Last Notification
Date of Abandonment:
Branch #
Date:
Date of Inventory:
SSN:
HOLDER NAME
OWNER NAME 1
(Last, First, and Middle Names)
ADDRESS
OWNER NAME 2
(Last, First, and Middle Names)
CITY,STATE, ZIP
MAILING ADDRESS
CITY,STATE, ZIP
Section II
Please check the box if these items are included in the Safe Deposit Box. A count or itemized description is not needed
Vital Statistics
Other Documents
Miscellaneous Papers
Birth Certificates
Life Insurance Polices
Letters/Postcards/School
Death Certificates
Income Tax Records/Receipts
Info/Licenses
Marriage Certificates
Bank Statements/Cancelled Checks/Etc.
Receipts and Other Misc. Papers
Service Records/Military or Other
Legal Documents/Agreements
SSN Records
Media
Last Will and Testament
Naturalization Papers
Photos/Negatives/Videos
Divorce Decrees
Cassettes/Diskettes/CDs/Etc.
Adoption Papers
Abstracts/Agreements/Deeds/Property Titles
Additional
Mortgages
Tangible Contents
Car Titles
Use form SDU-090103B
Passports
Section III
WE HEREBY CERTIFY THAT THIS IS A COMPLETE AND ACCURATE INVENTORY OF THE CONTENTS OF THE ABOVE SAFE
DEPOSIT BOX OPENED IN OUR PRESENCE. (PLEASE INDICATE THE NUMBER OF ADDITIONAL INVENTORY PAGES INCLUDED
WITH THIS REPORT _____________.)
Signature of bank officer
Date
Signature of other bank employee present
Date
Printed name and title of above officer
Date
Printed name and title of above employee
Date
Section IV
RELEASE OF CONTENTS
On ____ / ____/____ , upon receipt of $ , which represents:
Past Due Rent
Drill Costs
Storage Fees
The contents described in this inventory were released to , who has signed below to
acknowledge receipt of all of the contents as itemized and who hereby releases this institution from all responsibility.
Signature of person receiving contents
Date
Name and identification of recipient
Date
Signature of bank officer present
Date
Signature of other bank employee present
Date
State Controller's Office, Unclaimed Property Division
P.O. Box 942850, Sacramento, CA 94250-5873
Rev. 01/2011
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