Form Ac2709 - Verification And Checklist For Unclaimed Property (Page 2 of 2) in pdf

REPORTING ORGANIZATION

FEDERAL EMPL. ID NO.

Cash

1. Account Balances (5 years unless otherwise indicated)

A. Demand Deposit Account(s)

1A.$___________

B. Savings Accounts (includes Club Accts, Security Deposit and Retirement Accts)

1B.____________

C. Time Deposit Accounts

1C.____________

D. Money on Deposits to Secure Funds (if separate from A and B)

1D.____________

E. Unidentified Deposit (if separate from A and B) and Suspense Accounts

1E.____________

F. Escrow Funds (Mortgages, Performance Guarantee, Surety Bonds, etc.)

1F.____________

G. Credit Balances Arising from Loans (Includes Liquidated Mortgages,

1G.____________

Consumer Loans, Remainder of Collateral Amounts, etc.)

H. Credit Balances; Consumer Credit Accounts (3 years)

1H.____________

I. Credit Balances in Trading and Investment Accounts with Trusts, Brokers

1I._____________

Investment Firms (Including o/s checks issued to customers) (3 years)

J. Credit Balances or Cash Due Renters of Safe Deposit Boxes (3 years)

1J.____________

2. Negotiable Instruments (3 years unless otherwise indicated)

A. Certified Checks

2A.____________

B. Cashier, Teller Checks

2B.____________

C. Bank Money Order

2C.____________

D. Treasurer and Registered Checks

2D.____________

E. Drafts and Bank Traveler’s Checks

2E.____________

F. Warrants

2F.____________

G. Outstanding Checks Issued to Vendors (Accounts Payable)

2G.____________

H. Travelers Checks (non-bank) (15 years)

2H.____________

I. Licensed Money Transmitter Receipts and Money Orders (non-bank) (5 years)

2I._____________

J. State Checks (1 year)

2J. ____________

3. Paying Agents, Fiduciary, Mutual Funds, American Depository Receipt Accounts

and Corporations Disbursing Directly to Their Own Shareholders (3 years)

A. Cash Dividends (other than ADR)

3A.____________

B. Bond Interest (other than ADR)

3B.____________

C. Stock Dividends (other than ADR)

3C.____________

3P.___________

D. Distributions from Ownership of Interest (other than ADR) incl. Redemption

3D.____________

3Q.___________

Values, Warrants, Underlying and Unexchanged Shares and Accrued Dividends

E. Cash Dividends (ADR)

3E.____________

F. Stock Dividends (ADR)

3F.____________

3R.___________

G. Other Distributions Resulting from Ownership of Interest (ADR)

3G.____________

3S.___________

H. Bond Redemption

3H.____________

3T.___________

I. Mutual Fund and Dividend Reinvestment Book Shares

3I._____________

3U.___________

4. Investments, Trading (Broker/Dealer) and Bank Trust Department Accounts Representing

Distributions Received for Known and Unknown Owners (3 years)

A. Cash Over Receipts (Dividends and Other)

4A.____________

B. Bond Interest Over Receipts

4B.____________

C. Stock Over Receipts (Dividends and Other)

4C.____________

4P.___________

D. Other Over Receipts

4D.____________

4Q.___________

E. Unidentified Overages

4E.____________

4R.___________

F. Other Distributions Resulting from Ownership Interest or Debt Obligation

4F.____________

4S.___________

5. Refunds (Dormancy as indicated)

A. Utility Service Deposit (2 years)

5A.____________

B. Advance Payments for Utility Services Not Furnished (2 years)

5B.____________

C. Refunds Due on Overcharges by Utility Companies (2 years)

5C.____________

D. Refunds Due by Insurance Companies (3 years)

5D.____________

E. Amounts Due for Undelivered Goods and/or Services (3 years)

5E.____________

F. Rebates (3 years)

5F.____________

6. Insurance Proceeds (3 years unless otherwise indicated)

A. Limiting Age (Superannuated) Contracts (No dormancy period)

6A.____________

B. Matured Endowments

6B.____________

C. Death Claims

6C.____________

D. Amounts Due Under Policies of Insurance Other than Life

6D.____________

E. Refunds and other Amounts Due Under Policy Terms

6E.____________

F. Annuities

6F.____________

7. Funds Owing by Courts and Governmental Units (5 years)

A. Trust Funds

7A.____________

B. Bail Funds

7B.____________

C. Funds for Support of Spouse or Child

7C.____________

D. Condemnation Awards

7D.____________

X. Other

7X.____________

8. Other Amounts and Securities (Dormancy as Indicated)

A. Wages, Payroll, Salaries, Commissions, Pension Payments (3 years)

8A.____________

B. Unredeemed Gift Certificates (5 years)

8B.____________

C. Amounts Owed by Sales and Insurance Finance Companies (3 years)

8C.____________

D. Surplus from Sale of Pledged Property (1 year)

8D.____________

E. Lost Property (5 years)

8E.____________

F. Securities Long in Customers’ Trading, Investment, Trust Accounts (3 years)

8F.____________

8P.___________

G. Securities Held as Transfer Agent (3 years)

8G.____________

8Q.___________

H. Securities Held in a Vault or Storage Area of a Bank (3 years)

8R.___________

I. Securities Lost and Held by a Safe Deposit Company or Bank (5 years)

8S.___________

J. Securities Found in a Safe Deposit Box (3 years)

8T.___________

K. Other Securities Owed (3 years)

8K.____________

8U.___________

X. Late Filing Interest

8X.____________

Y. Other Miscellaneous Property

8Y.____________

8Z.___________

AC2709 (rev 08/10)

Reverse

Form Ac2709 - Verification And Checklist For Unclaimed Property Page 2

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