Form Upd601 - Report Of Unclaimed Property
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1Office of the Illinois State Treasurer
Unclaimed Property Division
PO Box 19496
Springfield IL 62794-9496
REPORT OF UNCLAIMED PROPERTY (UPD601)
Failure to complete this report in its entirety will result in an incomplete report which may result in fees and penalties
A
MAILING ADDRESS:
C
TYPE OF REPORT BEING FILED:
First Time Filing
Supplemental
20____ Annual Report
Other: ____________________
B
REPORT BEING FILED FOR:
D
REPORT CYCLE / LAST ACTIVITY:
May 1, 20___ December 31, 20___
November 1, 20___ July 1, 20___
E
MERGER
Name of Merging Company___________________________________________________________
FEIN_______________________________
Name and Address of Surviving or Parent Company ____________________________________________________________________________
______________________________________________________________________________________________________________________
________________________________________________________________________ FEIN of Surviving or Parent Company_______________
F
REQUIRED INFORMATION
Contact Person
Contact Phone
Contact Fax
Type of Business
FEIN
State of Inc
Date of Inc
Email
Employees ____________
Annual Sales/Premiums ________________
Total Assets ________________
(From Most Recent Tax Return)
(From Year End Balance Sheet)
DID YOU PERFORM THE DUE DILIGENCE FOR THIS REPORT?
[
] Yes
[
] No
Amount of Cash Remitted
Number of Shares
Number of Owners
NTR (Nothing to Report)
Check
PAYMENT INFORMATION
ACH
DTC
PLEASE ATTACH CHECK AND/OR SECURITY DOCUMENTS MADE PAYABLE TO: ILLINOIS STATE TREASURER
G
VERIFICATION
I hereby verify, under penalties of perjury, that the facts contained herein are true, and I am duly
authorized to execute this verification by the holder and by law. If made by a partnership shall be executed by a partner, if made by
an unincorporated association or private corporation, by an officer, and if made by a public corporation, by its fiscal officer (Section 11(f)
of the Act).
Signature (if unsigned, report will be returned)
Date
Print Name & Title of Officer Signing Report
Phone
FOR OFFICE USE ONLY
CMP
ACCOUNTING
RELOG
PREV
TECHREV
DE
CLEARED
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