Form Tr-0392 - Annual Report Of Unclaimed Property Verification & Affidavit Of Safe Deposit Items For Year Ended December 31 Page 2

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PAGE NO. ______ OF______
REPORT DATE _________________
STATE OF TENNESSEE
TREASURY DEPARTMENT
FOR YEAR ENDED ______________
PAGE TOTAL $___________
NAUPA CODE: SD01, SD02, SD03
IV. REPORT OF UNCLAIMED
SAFE DEPOSIT PROPERTY
DATE
INSERT
HOLDER NAME ___________________________
BOXES OPENED
DISPOSITION DATE
AND INVENTORIED
FOR (9) AND (10)
HOLDER NUMBER ________________________
_________________
_________________
HOLDER FEDERAL TAX ID NO. ______________
Owner's Name and Last
Relationship
Safe Deposit
Net Amount
Cash Amount
If
Returned,
Net Proceeds
Between
Box or
Deposited
Sold
Known Address
Remitted
Sent
Paid With
(Alpha by Owner)
Owners
Identifying
to Lessee's
or
With Initial
With
Disposition
and Date of Last Activity
(If Applicable)
SSN/FEIN
Number
Contents*
Account
Report
Destroyed
Report
Report
(2)
(4)
(5)
(6)
(9)
(1)
(3)
(7)
(8)*
(10)
Note: Remit by Check
$
$
0.00
0.00
(11) Remit Total
Please provide all data requested.
*If cash or securities, send to State of Tennessee.
Per rule 1701-2-1-.37, report contents of safe deposit box separate from other property types.
TR-0392 (Rev. 10/05)
RDA 1153

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