Form Tr 0201 - Cover Letter Verification & Affidavit Of Items/annual Report Of Unclaimed Property

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STATE OF TENNESSEE TREASURY DEPARTMENT
Reset Form
Unclaimed Property Division
P.O. Box 198649 Nashville, Tennessee 37219-8649 (615) 253-5362
UCP.holders@state.tn.us
I. COVER LETTER
VERIFICATION & AFFIDAVIT OF ITEMS FOR YEAR ENDED DECEMBER 31, 20____
A. Holder # _______________________________
Report # (required if E-mail, ACH or Wire) _________________________
Indicate Changes to Name or Address Below
Name
___________________________________________
__________________________________________________
Type name and address or use pre-printed form.
Address
___________________________________________
__________________________________________________
___________________________________________
__________________________________________________
___________________________________________
__________________________________________________
E-Mail
___________________________________________
State of Incorporation ________________________________
Fed Tax ID # ___________________________________________
Date of Incorporation ________________________________
Name of contact person or department designated to respond to unclaimed property inquiries:
Name
___________________________________________
__________________________________________________
Telephone
___________________________________________
__________________________________________________
E-mail
___________________________________________
__________________________________________________
B. Type of company (see Reporting Instructions for list): _____________________________________________________________
C. Type of report:
Annual
Negative (No property to report.)
D. Method of reporting:
Diskette or CD
E-Mail
Paper
E. Total properties reported: _____________________________________________________________________________________
F. Cash
Penalty failure to
Penalty failure to
Property: $ __________________
report by May 1: $__________________
remit by May 1: $ __________________
G. Total cash remitted (make check payable to "Treasurer State of Tennessee"): $ __________________________________________
H. Payment method:
Check
ACH
Wire
Check, Wire or ACH # _______________ DFI # ____________________
I. Delivery and registration of shares remitted: (see instructions)
J. Total number of DTC book entry shares remitted: __________________________________________________________________
K. Total number of physical securities remitted: _____________________________________________________________________
L. Total number of mutual fund shares remitted: _____________________________________________________________________
M. Total number of shares transferred: ____________________________________________________________________________
N. Enclose confirmation of delivery of shares and mutual fund statements.
O. Indicate if you have safe deposit box contents to report:
No
Yes (see instructions)
P. VERIFICATION AND AFFIDAVIT: The undersigned,____________________________________________, declares, under
penalty of perjury, that, to the best of (his/her) knowledge, the foregoing report and supporting records, contain a full, true and complete
report of unclaimed property now in the possession or under the control of the holder, which is presumed abandoned in accordance with
the provisions of Tennessee Code Annotated, Sections 66-29-101 through 66-29-153. I have attempted to contact property owners
at their last known address by first-class mail not more than one hundred twenty days and no less than sixty days prior to the
filing date of the report. I am duly authorized to attest to this.
Date __________________________________________
___________________________________________________
Signature of Chief Financial Officer (TCA 66-29-113(f)(g))
State of ________________________________________
___________________________________________________
Title
Telephone Number
City/County _____________________________________
Subscribed and sworn to before me this ______ day of ___________________ 20____
SEAL
(required)
Notary Public ___________________________________
REPORT AND REMITTANCE DUE MAY 1
TR0201 (Rev. 11/2002)
RDA 1153

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