MONTANA
Clear Form
UCH-2
Rev 10 10
Report of Property Presumed Unclaimed
Inventory Listing Sheet to Report Contents of Safe Deposit Boxes
Name of Holder ___________________________
Name of Contact __________________________
Address _________________________________
Address _________________________________
Address _________________________________
Address _________________________________
City, ST, Zip ______________________________
City, ST, Zip ______________________________
Phone _____________ E-Mail _______________
Phone _____________ E-Mail _______________
1. FEIN:
Ext #:
2. Account ID:
3. Report Year:
4. Report #: _______ Your original report is
considered report #1, please see instructions.
5. If you are no longer in business and want your
If this is an amended return, check here.
account cancelled, check here.
Enter fi nal date. ___________________
6. If your address has changed, check here.
Section I:
7. Safe Deposit Box or Safekeeping Number
8. Social Security Number of Owner
9. Name (last, fi rst, middle initial) of Owner
10. Address of Owner
Address
Address
City
State
Zip Code
11. Date Rental Expired
12. Rental Charges
$
13. Drilling or Opening Fees
$
14. Total Bank Charges
$
I, the undersigned, declare under penalty of perjury, that to the best of my knowledge and belief, the following
is a true and complete report of unclaimed property now in possession or under control of the holder, which is
presumed unclaimed in accordance with Montana law, 70-9-801 through 70-9-829, MCA. Written notice has
been sent to the apparent owner as prescribed under Montana law, 70-9-808(5), MCA.
Name of Offi cer or Holder Authorized to Sign Report (please print) __________________________________
Signature ______________________________________________________ Date ____________________
Title __________________________________ Phone __________________ Fax _____________________
Mail this report to:
Ship the safe deposit property to:
Unclaimed Property
Attn: Cathy Fitzgerald, Unclaimed Property
Montana Department of Revenue
Montana Department of Revenue
PO Box 5805, Helena MT 59604-5805
2517 Airport Rd, Helena, MT 59601
Questions? Call toll free (866) 859-2254 (in Helena, 444-6900).