Form Upc 4 - Report Of Unclaimed Property
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4REPORT OF UNCLAIMED PROPERTY
Holder ______________________________________________ _____________________________
Page ____
State of South Dakota
of _____
Office of the State Treasurer
FILE THIS COPY BEFORE NOVEMBER 1
Unclaimed Property Division
(Name of Business)
(South Dakota Holder ID Number)
500 East Capitol Ave.
_____________________________________________________ _____________________________
Report Year
(MAY 1 FOR LIFE INSURERS)
Pierre, SD 57501-5070
20____
(Mailing Address)
(Federal Tax Identification Number)
_____________________________________________ Period Covered ___________________ to _____________
(City)
(State)
(Zip Code)
(Month, Day, Year)
(Month, Day, Year)
SEE
SEE INSTRUCTIONS ON REVERSE
INSTRUCTIONS
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DATE OF LAST
AMOUTNT DUE
T
AMOUNT
PROPERTY
TRANSACTION
AMOUNT
Y
OWNER BEFORE
DEDUCTED
OR
OWNER’S LAST NAME, FIRST AND MIDDLE
MAILING ADDRESS, CITY, STATE, ZIP CODE
REPORTED
TYPE
OWNER’S SOCIAL
P
IDENTIFYING
DATE PROPERTY
DEDUCTIONS AND
OR WITHELD
E
CODE
SECURITY NUMBER
NUMBER
BECAME
WITHHOLDINGS
(b)
(a)
PAYABLE,
REDEEMABLE
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RETURN ORIGINAL
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Parent category: Financial