Section A Holder Reporting Information - Missouri State Treasurer, Unclaimed Property Report Checklist Page 2
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1
2
3SECTION B
FILE THIS REPORT WITH YOUR REMITTANCE ON NOVEMBER 1 (MAY 1 FOR LIFE INSURERS).
PAGE NO
ALL ITEMS LESS THAN $50 MAY BE REPORTED IN AGGREGATE AND ENTERED BY PROPERTY
_____ of
SUMMARY OF UNCLAIMED PROPERTY
TYPE AT THE END OF THIS REPORT.
_____
SEE INSTRUCTIONS
HOLDER NUMBER
HOLDER NAME
REPORT PERIOD ENDING
(IF ADDITIONAL SPACE IS REQUIRED, PLEASE DUPLICATE
THIS FORM)
DATE OF LAST
OWNER SOCIAL
CHECK THIS BOX
AMOUNT
PROP CODE
TRANSACTION.
ORIGINAL OWNER
OWNER STREET
CITY, STATE, ZIP,
ACCT/
PROPERTY
SECURITY
IF INTEREST
DUE
DATE PROP.
(SEE APP. A)
NAME
ADDRESS
COUNTY
CHECK
DESCRIPTION
NUMBER AND/OR
BECAME PAYABLE,
BEARING
OWNER
(LIST BY LAST NAME,
NUMBER
REDEEMABLE, OR
DATE OF BIRTH
ACCOUNT
FIRST NAME, MI)
RETURNABLE
$
DEDUCTED EXPENSES SUMMARY NONE DEDUCTED
PAGE TOTAL
If expenses have been deducted per RSMo 447.543, please outline these costs
below:
NO. ITEMS THIS PAGE
$
ITEM DESCRIPTION
AMOUNT
GRAND TOTAL
(IF LAST PAGE)
ITEM DESCRIPTION
AMOUNT
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