Holder Information Form - Nebraska State Treasurer'S Office Unclaimed Property Division Page 2
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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
Place a checkmark by the category which most closely describes your organization:
Banking / Trust
Other Business Association
Schools, Colleges
Savings & Loan
Retail
Churches
Credit Union
Construction
Health Care Facilities
Life Insurance
Services
Government
Other Insurance
Manufacturing
Utilities / Cable
Mutual funds
Transportation
Reciprocal
Finance / Investments
Oil & Gas
If you are a non-insurance entity:
If you are an insurance company:
List your number of shareholders: _________
List number of policies in force: __________
List dollar volume of sales for last fiscal year:
List dollar volume of sales for last fiscal year:
__________________________________________________
__________________________________________________
State of _________________
County of ________________
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
$__________ as to property presumed abandoned under the Nebraska Unclaimed Property Act for the
year ending as stated; that I am duly authorized by the holder herein to execute this report; and I believe
that said report is true, correct and complete as of said date, exception for such property as has ceased
to be abandoned.
Signature of Company Representative: ______________________________________________
Title of Company Representative: __________________________________________________
Subscribed and sworn to before me
(Please Place
Notary Seal Here)
this _____ day of ______, 20__
Signature of Notary: ________________________________________________________________________
Mailing Address:
Delivery Address:
Nebraska State Treasurer
Nebraska State Treasurer
Nebraska State Treasurer
Unclaimed Property Division
Unclaimed Property Division
Unclaimed Property Division
P.O. Box 94788 - Capitol Building
809 P Street
5800 Cornhusker Hwy, Bldg. 2 Ste. 4
Lincoln, NE 68509
Lincoln, NE 68507
Lincoln, NE 68508-1390
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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