Form Tr 0201 - Cover Letter Verification & Affidavit Of Items/annual Report Of Unclaimed Property Page 2

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STATE OF TENNESSEE
If additional pages are needed,
REPORT DATE _________________
TREASURY DEPARTMENT
please print each completed
FOR YEAR ENDED ______________
page before resetting form.
II. ANNUAL REPORT
OF UNCLAIMED PROPERTY
FEDERAL EMPLOYER
HOLDER NAME ______________________________
ID NUMBER ____________________
HOLDER NUMBER ___________________________
Owner's Last Name,
Date of Last
Activity and
First Name, Middle Name,
Relationship
Title Owner's Last Known
Between
Cash
Security Name
Security
Number
Additional
Amount
Interest
Cusip
Street Address,
Owners
Property
or
of Shares
Information
Type
Remitted
Rate
Name of Mutual Fund
Number
Remitted
(i.e., DOB)
City, State, Zip
(If Applicable)
SSN/FEIN
(6)
(1)
(4)
(5)
(7)
(8)
(9)
(10)
(2)
(3)
0
(11) Remit Total
$
0.00
(12) PAGE NO. ______ OF______
NUMBER OF PROPERTIES _________
PAGE TOTAL $____________________
TR 0201 (Rev. 11/2002)
RDA 1153

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