Form Tr-0201 - Verification & Affidavit Of Items - 2012
Download a blank fillable Form Tr-0201 - Verification & Affidavit Of Items - 2012 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Tr-0201 - Verification & Affidavit Of Items - 2012 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Reset Form
STATE OF TENNESSEE
TREASURY DEPARTMENT
Unclaimed Property Division
P.O. Box 198649
Nashville, Tennessee 37219-8649
(615) 253-5362
UCP.holders@tn.gov
VERIFICATION & AFFIDAVIT OF ITEMS FOR YEAR ENDED DECEMBER 31, 20____
A. Holder #
________________________________
Report # (required if E-mail, ACH or Wire) __________________
Indicate any changes to information below in red ink:
Name
________________________________________
__________________________________________
Address
________________________________________
__________________________________________
________________________________________
__________________________________________
Fed Tax ID # ________________________________________
State of Incorporation _________________________________
Date of Incorporation _________________________
Name of contact person or department designated to respond to unclaimed property inquiries:
Name
________________________________________
Telephone
________________________________________
E-mail
________________________________________
B. Type of Company (see Reporting Instructions for list): ________________________________________________________
C. Type of Report:
Annual
Negative (no property to report)
D. Method of Reporting:
Encrypted Diskette or CD
E-Mail (No paper reports allowed.)
E. Total Properties Reported:
F. Cash Property: $ ________________________________
Penalty Failure to Report by May 1: $ ___________________
Penalty Failure to Remit by May 1: $ ___________________
$0.00
G. Total Cash Remitted (make check payable to "Treasurer, State of Tennessee"): $ ____________________________________
H. Payment Method:
Check
ACH
Wire
Check, Wire or ACH # ___________ DFI # _____________
I.
Delivery and Registration of Shares Remitted: (see instructions)
J. Total Number of DTC Book Entry Shares Remitted: __________________________________________________________
K. Total Number of Physical Securities Remitted:
____________________________________________________________
L. Total Number of Mutual Fund Shares Remitted: ____________________________________________________________
M. Total Number of Shares Transferred:
____________________________________________________________
N. Enclose Confi rmation of Delivery of Shares and Mutual Fund Statements.
O. Indicate if You have Safe Deposit Box Contents to Report:
No
Yes (see instructions)
P. VERIFICATION AND AFFIDAVIT: The undersigned,_____________________________________________, declares,
under penalty of perjury, that, to the best of (his/her) knowledge, the foregoing report and supporting records contain a full,
true and complete report of unclaimed property now in the possession or under the control of the holder, which is presumed
abandoned in accordance with the provisions of Tennessee Code Annotated, Sections 66-29-101 through 66-29-153. I have
attempted to contact property owners at their last known address by fi rst-class mail not more than 120 days and no
less than 60 days prior to the fi ling date of the report. I am duly authorized to attest to this.
Date
______________________________________
_______________________________________________
Signature of Chief Financial Offi cer (TCA 66-29-113(f)(g))
State of
______________________________________
_______________________________________________
Title
Telephone Number
City/County ______________________________________
Subscribed and sworn to before me this _______ day of ___________________ 20____
SEAL
(required)
Notary Public ____________________________________
TR-0201 (Rev. 01/12)
RDA 1153
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal