Form Rev 80 0004-2 - Summary Report For Unclaimed Property - Washington State Department Of Revenue

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WARNING:
To protect against the possibility of others accessing your confidential
information, do not complete these forms on a public workstation.
Washington State
Department Of Revenue
Summary Report
Unclaimed Property Section
PO Box 47489
Olympia, WA 98504-7489
for Unclaimed Property
( 360) 705-6706
Reset This Form
Report and Payment Due by November 1
Washington Holder Number
Business Name:
Federal ID Number
Report Year
Sequence Number
Attn or in care of:
Date & State of Incorporation
UBI Number
Mailing Address:
Primary Business Activity
City, State, Zip:
Date Received (offi ce use only)
Contact Person:
(
)
Name
Telephone Number
E Mail Address
Inactive Account:
Check here if you do not anticipate having property to report.
NOTE: You will need to request report forms or other communications if
you need to report in the future.
Close Account:
Check here if your business is closing or is closed.
Summarize below types of property being reported.
Category Code
Amount
Category Code
Amount
$
$
$
$
$
$
$
$
$
Safe Deposit Boxes
#
Symbol
Share Quantity
Certifi cate No./DTC
CUSIP No.
Total Names
Signature
Title
Total Shares
Date
MAILING ADDRESS:
Department of Revenue
Total Cash
Unclaimed Property Section
PO Box 47489
$
Olympia, WA 98504-7489
Mail this form with your report (paper, cartridge, or diskette) and remittance by November 1.
For tax assistance visit or call 1-800-647-7706. To inquire about the availability of this document in an alternate format
for the visually impaired, please call (360) 705-6715. Teletype (TTY) users may call 1-800-451-7985.
REV 80 0004-1 (07/26/07)
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