Holder Information Form - Nebraska State Treasurer'S Office Unclaimed Property Division
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1
2Nebraska State Treasurer’s Office
Unclaimed Property Division
5800 Cornhusker Hwy, Bldg. 2 Ste. 4,
809 P Street
Lincoln, NE 68507
Lincoln, NE 68508-1390
Holder Information
Company or Organization: _________________________________________________________
Address: _______________________________________________________________________
City: __________________________________________________ State: _____ Zip: __________
Federal Tax ID#: _________________________________________________________________
State of Incorporation: ____________________________________________________________
Date of Incorporation: _____________________________________________________________
Report for Period Ending: _________________________________________________________
Contact Person for Report: ________________________________________________________
Phone: ________________ Fax: ________________ E-Mail: _____________________________
Previous Holder Information:
(Only applicable if there has been a name change, merger, etc.)
Name:__________________________________________________________________________
Address: _______________________________________________________________________
City: ___________________________________________ State: _________ Zip: ____________
Federal ID Number: _________________ Date of Acquisition / Name Change: ______________
Did you file a report of Unclaimed Property last year?
YES
NO
If yes, please provide amount and date remitted: __________________
__________________
Amount
Date
If no, please explain: __________________________________________________________
Nebraska State Treasurer Shane Osborn | | 402.471.8497 | 809 P Street, Lincoln, NE, 68508-1390
Nebraska State Treasurer Don Stenberg
Nebraska State Treasurer Shane Osborn | | 402.471.8497 | 5800 Cornhusker Hwy, Bldg. 2 Ste. 4, Lincoln, NE 68507
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