Form 496-Up - Report Of Unclaimed Property Verification And Checklist - 2010 Page 2
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1
2Insurance
Yes
No
Code
Description
Yr
Yes
No
Code
Description
Yr
___
___
INO1
Individual Policy Benefits or Claim Payments 5
___
___
IN06
Unidentified Remittances
5
___
___
INO2
Group Policy Benefits or Claim Payment
5
___
___
IN07
Other Amounts Due Under Policy Terms 5
___
___
INO3
Proceeds Due Beneficiaries
5
___
___
IN08
Agent Credit Balances
5
___
___
INO4
Proceeds from Matured Policies,
5
___
___
IN09
Proceeds from Demutualization
2
Endowments, or Annuities
___
___
IN10
Shares of Stock from Demutualization
2
___
___
IN05
Premium Refunds
5
___
___
IN99
Aggregate Insurance Property
5
Court Deposits
___
___
CTO1
Escrow Funds
1
___
___
CT04
Suspense Accounts
1
___
___
CTO2
Condemnation Awards
1
___
___
CT05
Other Court Deposits
1
___
___
CTO3
Missing Heirs’ Funds
1
___
___
CT99
Aggregate Court Deposits
1
Mineral Proceeds and Mineral Interests
___
___
MIO1
Net Revenue Interest
5
___
___
MI06
Bonuses
5
___
___
MIO2
Royalties
5
___
___
MI07
Delay Rentals
5
___
___
MIO3
Overriding Royalties
5
___
___
MI08
Shut-In Royalties
5
___
___
MIO4
Production Payments
5
___
___
MI09
Minimum Royalties
5
___
___
MIO5
Working Interest
5
Trust, Investment, and Escrow Accounts
___
___
TRO1
Paying Agent Accounts
5
___
___
TR04
Escrow Accounts
5
___
___
TRO2
Undelivered or Uncashed Dividends
5
___
___
TR05
Trust Vouchers
5
___
___
TRO3
Funds Held in Fiduciary Capacity
7
___
___
TR99
Aggregate Trust Property
5
Safe Deposit Boxes and Safekeeping
___
___
SDO1
Safe Deposit Box Contents
5
___
___
SD03
Other Tangible Property
5
___
___
SDO2
Other Safekeeping
5
** IRA’s are reportable 7 years after the participant has attained the age of 70 1/2.
Please indicate the primary business activity of your company ________________________________________________________________________
Did you file a report of unclaimed property last year: YES ______
NO ______ If no, please explain: _______________________________________
Contact Person: ___________________________________________________________________ Telephone Number: ________________________
* Please include contact information for both report and claim situations (if separate).
Address:__________________________________________________________________________________________________________________
State of ___________________________________________________:
County of _________________________________________________: SS
I, _________________________________________________________________, being first duly sworn, on oath depose and state that I have caused
to be prepared and have examined this report consisting of ________ pages totaling $ ____________, ______________ shares, and ____________
safekeeping items as to property presumed abandoned under the Oklahoma Unclaimed Property Law for the year ending as stated, that I am duly
authorized to execute this verification by the holder and by law and that I believe that said report is true, correct and complete as of said date, excepting
for such property as has since ceased to be abandoned.
Signature ________________________________________________________________
Title ____________________________________________________________________
Subscribed and sworn to before this _______________ day of ___________________________, _________________.
Notary Signature: _________________________________________________________________________________
My Commission Expires the __________________ day of _____________________________, _________________.
Mail reports and make checks payable to:
Oklahoma State Treasurer
Unclaimed Property Division
rd
2401 NW 23
St., Suite 42
Oklahoma City, Oklahoma 73107
Reporting: (405) 521-4275
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