Form St77 - Report Of Unclaimed Property - 2010

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(ST77)
R
U
P
EPORT OF
NCLAIMED
ROPERTY
F
Y
E
D
31, 2010
OR THE
EAR
NDING
ECEMBER
THIS FORM MAY ONLY BE USED TO REPORT 3 OR LESS PROPERTIES
HRS P
ALL OTHER HOLDERS MUST FILE ELECTRONICALLY
USE
RO AT
Holder Name:
State of Connecticut
Office of the State Treasurer
Holder Tax ID#:
Unclaimed Property Division
Address:
55 Elm Street, 5
th
Floor
____________________________________________________________
Hartford, CT 06106
____________________________________________________________
____________________________________________________________
File Originals with your remittance on or before March 3 0, 2011
St. of Incorporation:
Contact Name:
State of ___________________________ County of __________________________
Contact phone:
Contact Email:
I, _______________________________________ being first duly sworn, on oath depose and state that I have caused to be prepared and have examined this report hereto totaling
$______________, # of shares_______________ and # of properties ___________ as to property presumed abandoned under Connecticut Unclaimed Property Law for the year ending as
stated, and that I am duly authorized to execute this verification by holder and by law and that I believe that said report is true, correct and complete as of said date, excepting for such
property as has since ceased to be abandoned.
Signature _______________________________________
Title _______________________________ Notary Signature (and Seal) ____________________________
Type or Print Neatly Using Black Ink
Date of Last
Transaction or Date
NAUPA
property became
CODE #
Payable,
(Property
Owner’s Last Name, First name, Initial, Street Address, City, State, Zip
Owner’s Social
Redeemable or
Total Remitted
Code)
Code (List Alphabetically by last name)
Security Number
returnable
and Due Owner
(1)
(2)
(3)
(4)
(5)
Total:
Form ST77: Revised 11/2010

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