Form Ac2709 - Verification And Checklist For Unclaimed Property

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AC2709 (Rev 08/10)
New York State Comptroller
OFFICE OF UNCLAIMED FUNDS
th
110 State Street, 8
Floor
Albany, New York 12236
VERIFICATION AND CHECKLIST FOR UNCLAIMED PROPERTY
REPORTING ORGANIZATION
VERFICATION FOR PERIOD ENDED
, 20
STATE OF INCORPORATION
(name of business)
DATE OF INCORPORATION
(area or department, e.g., Corp Trust Division)
ARE YOU AUTHORIZED TO DO BUSINESS IN NYS?
(street address)
FEDERAL EMPL. ID NO
(street address)
CONTACT PERSON
(city, state, zip code)
CONTACT TITLE
CONTACT PHONE (
)
(service bureau, if used)
CONTACT FAX (
)
(service bureau contact name)
ADDRESS
(service bureau contact phone)
State of
SS:
County of
EMAIL ADDRESS
I certify that I am a duly authorized officer of the above named organization. To the best of my knowledge and belief this
report is a true and complete statement of all abandoned property held by, or owing by, this organization as of the report
period end date.
__________________________________
Signature
Subscribed and sworn before
Totals: Cash
_____________
me, this
day of
20
Issues
_____________
Shares
_____________
Signature of Notary Public or Commissioner of Deeds
Payment Type:
Electronic
Title
Check
Securities
RESERVED FOR USE OF STATE COMPTROLLER
Amount Received
Date Received Ack. Number
Media Type
Class
Report Sequence
Year
Comments
Be sure to complete the checklist on the back of this sheet, indicating types and amounts of property being
reported. Also, please verify that the property type(s) used on this form are the same as the ones used in your
detailed Report of Abandoned Property. Detailed instructions for completing this form are in the Handbook for
Reporters of Unclaimed Funds.

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