Form 497-Up-Mir - Report Of Unclaimed Property

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Page __________
Of ____________
OKLAHOMA STATE TREASURER
HOLDER
State of Oklahoma
Unclaimed Property Division
2300 N. Lincoln Blvd., Rm. 217
(City)
(State)
(Zip)
Oklahoma City, Okahoma 73105-4895
FEDERAL EMPLOYER ID NO.
REPORT YEAR
REPORT OF UNCLAIMED PROPERTY
Note: According to chapter 80 735:80-3-5 "Regardless of the amount of the mineral interest proceeds, if the proceeds are presumed unclaimed under the Uniform Unclaimed Property Act, or under the Unclaimed Property Laws of any other 
State, the mineral interest that generated such proceeds is also presumed abandoned and shall become reportable to OST. It is also required that the names of last-known owners of mineral interest, their percentages of ownership and the
 legal description of the mineral interest be reported to OST."
PROPERTY
NAUPA
AMOUNT
ADDITIONS
DEDUCTIONS AND
AMOUNT
LEGAL
WELL
OWNER
DATE OF LAST
OWNER'S LAST NAME, FIRST NAME, MIDDLE NAME
OWNER'S SOCIAL
DESCRIPTION PROPERTY
REPORTED
TO AMOUNT
WITHHOLDINGS
REMITTED
DESCRIPTION
NAME
PERCENTAGE
TRANSACTION OR
LAST KNOWN STREET NAME
SECURITY NUMBER
OWNER
CODE
AS DUE OWNER
REPORTED TYPE
* AMOUNT
COUNTY NAME & STATE
DATE PROPERTY
CITY, STATE, ZIP
OR FEI NUMBER
NUMBER
*(See note below)
SECTION, TOWNSHIP, RANGE
BECAME PAYABLE
(1)
(2)
(3)
(4)
(5a)
(5b)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
0.00000000%
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
497-UP-MIR
(IF THIS IS LAST PAGE OF REPORT, ENTER GRAND TOTAL)
Revision 10/04/2016
*Must be entered as a negative number in column 5b.

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