Form 04-720a - Verification For Unclaimed Property
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1DUE DATE
Alaska Department of Revenue
STATE OF ALASKA
November 1, 1998
Income and Excise Audit Division
PO Box 110420
VERIFICATION FOR UNCLAIMED PROPERTY
Voice (907) 465-4653
Fax (907) 465-2375
Instructions: Complete this form and attach it to Form 04-720B
Report of Unclaimed Property: Mail your report and remittance on or before November 1.
Report Year Ending
Period Covered
June 30, 1998
HOLDER INFORMATION
Federal EIN
Site Location Number
Holder
Type
(if known)
Circle one of the following:
Name
Bank
Mutual Fund
Credit Union
Oil & Gas
Business Name
Government, State, Local, Fed.
Retail
Health Care Facility
Safe Deposit Co
Address
Hospitals
Savings & Loan
Insurance Co. (Casualty)
Schools & Colleges
Insurance Co. (Life & Casualty)
Trust Company
City
State
Zip Code
Insurance Co. (Life)
Utility
Manufacturer
Other
State of Incorporation
Date Incorporated
Contact Person
Address (if different from above)
E-Mail Address
Contact Telephone Number
Fax Number
CHANGE OF HOLDER INFORMATION (List former name, address or federal EIN)
Date of Change
Former Name
Former Address
Former Federal EIN
AGENT INFORMATION (If filed by agent, complete the following)
Agent Name
Agent Federal EIN
REMITTANCE
Total Amount Remitted (included with report)
Total Shares Remitted (with report)
Total Shares Remitted (Depository Trust Corp.)
YOUR REMITTANCE MUST ACCOMPANY REPORT
State (Province) of______________________________:SS
I, _________________________, being first duly sworn, on oath depose and state that I have cause to be prepared and have examined this
report consisting of ______pages totaling $ _________________as to property presumed abandoned under the Alaska Unclaimed Property Act
for the year ending as stated; that I am duly authorized by the holder herein to execute this report; and that I believe said report is true,
correct and complete as of said date, excepting for such property as has since ceased to be abandoned.
Signature _______________________________
Print Name _________________________________
Title ____________________________________
Subscribed and Sworn to me before this ______ day of ______________________________, 19__________
Signature ________________________________
Print Name __________________________________
Notary Public for: ___________________________
My Commission expires: __________________________
Office Use Only
Validation Number
Note: The 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, the chief financial officer.
P.M.D.
(Please Read General information and instructions)
Form 04-720A (R 8/97)
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