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Section A Holder Reporting Information - Missouri State Treasurer, Unclaimed Property Report Checklist

STATE TREASURER ERIC SCHMITT

MAIL COMPLETED REPORT AND REMITTANCE TO:

MISSOURI STATE TREASURER'S OFFICE

REPORT OF UNCLAIMED PROPERTY

UNCLAIMED PROPERTY

P.O. BOX 1272

SECTION A

JEFFERSON CITY, MISSOURI 65102-1272

HOLDER REPORTING INFORMATION

PART I REPORT INFORMATION

DATE PREPARED

REPORT PERIOD ENDING

FEDERAL I.D. NUMBER

HOLDER NUMBER

TOTAL NO. OF ITEMS

TOTAL NO. OF SHARES

TOTAL NO. OF SAFE

CHECK NUMBER

CHECK AMOUNT

DEPOSIT BOXES

PART II HOLDER INFORMATION

THIS REPORT INCLUDES:

ALL BRANCHES AND DIVISIONS

ALL SUBSIDIARIES

ONLY THIS COMPANY/BRANCH/DIVISION

NAME OF HOLDER

STATE OF INCORPORATION

MAILING ADDRESS

DATE OF INCORPORATION

CITY STATE ZIP COUNTY

PRIMARY PLACE OF BUSINESS IN MISSOURI (CITY, COUNTY, ZIP)

PROVIDE PREVIOUS HOLDER INFORMATION IF YOU ARE A SUCCESSOR TO PREVIOUS HOLDERS OF THE PROPERTY. IF YOU HAVE

CHANGED YOUR NAME OR ADDRESS DURING THE TIME PERIOD THAT YOU HAVE HELD THE PROPERTY, LIST THE PRIOR NAME(S) AND

ADDRESS(ES) YOU HAVE REPORTED UNDER.

PART III PREVIOUS HOLDER INFORMATION

PREVIOUS NAME OF BUSINESS

FEDERAL I.D. NO.

HOLDER NUMBER

DATE OF CHANGE

PREVIOUS ADDRESS (STREET, CITY, STATE, ZIP)

PART IV PRIMARY BUSINESS ACTIVITY INFORMATION

PLEASE PROVIDE A BRIEF BUSINESS DESCRIPTION

PART V CONTACT PERSON

CONTACT PERSON

TITLE

PHONE NUMBER EXTENSION

FAX NUMBER

PART VI AUTHORIZATION

I, ____________________________________________being first duly sworn under oath, state that I have examined this report

of property presumed abandoned under the Missouri Unclaimed Property Act, and that I am duly authorized by the Holder herein to

execute this report; and I declare by penalty of perjury that this report is true, correct, and complete, as of said date.

SIGNATURE

TITLE

NOTE: This verification, 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 chief fiscal officer.

MO 272-1112 (8-98)

FOR OFFICE USE ONLY

PROCESSED BY ____________ VERIFIED BY ____________ KEYED BY ____________

Section A Holder Reporting Information - Missouri State Treasurer, Unclaimed Property Report Checklist

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