Form Up-1c - Report Of Unclaimed Safe Deposit Box Contents
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1Report of Unclaimed Safe Deposit Box Contents
Holder Name: __________________________________________________________
CHECKLIST
For Department Use Only (initials)
(
)
YOUR COMPANY NAME
Ì Papers
Ì Inventoried By ___________________
Tax ID Number: _________________________ Report Year:___________________
Ì Currency
Ì Verified By ______________________
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)
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FEDERAL EMPLOYER IDENTIFICATION NUMBER
ENTER THE YEAR COVERED BY THIS REPORT
Ì Jewelry
Allowed Amounts.
Ì Stocks
Ì Rental Charges __________________
Period Covered: ___________ to ___________ Page ___________ of ___________
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)
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ENTER THE PERIOD COVERED BY THIS REPORT
ENTER THE PAGE NUMBER OF THIS REPORT
Ì Saving Bonds
Ì Drilling Fees ____________________
One Safe Deposit Box Per Page (this form may be reproduced as needed)
Safe Deposit Box Number
Date of Abandonment
(
,
,
)
MONTH
DAY
YEAR
Branch where Property Was Held
Owner Information
Branch Name
Street or PO Box
Social Security Number
Date of Birth
City
State
Zip Code
Owner’s Mailing Address
Amount Due Holder
TYPE
AMOUNT
Street or PO Box
Drilling . . . . . . . . . . . . . . . . . . . .$ _________________________
Unpaid Rent . . . . . . . . . . . . . . . .$ _________________________
Safekeeping . . . . . . . . . . . . . . . . .$ _________________________
City
State
Zip Code
Other . . . . . . . . . . . . . . . . . . . . . .$ _________________________
Total $ _________________________
Itemized Description of Contents
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)
ONE ITEM PER LINE OR ATTACH ITEMIZED LIST
1. ___________________________________________________________
8. ___________________________________________________________
2. ___________________________________________________________
9. ___________________________________________________________
3. ___________________________________________________________
10. ___________________________________________________________
4. ___________________________________________________________
11. ___________________________________________________________
5. ___________________________________________________________
12. ___________________________________________________________
6. ___________________________________________________________
13. ___________________________________________________________
7. ___________________________________________________________
14. ___________________________________________________________
A computer printout with the required information is acceptable for 10 items or fewer. Electronic files are required for more than 10 items.
UP-1C 6/07
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Parent category: Legal