Report Of Unclaimed Property - Nevada State Treasurer
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1Nevada State Treasurer
Report of Unclaimed Property
(Remittance must accompany report)
Make check payable and mail to: Nevada Unclaimed Property
555 E Washington Avenue, Suite 4200, Las Vegas, NV 89101-1070
HOLDER INFORMATION
Insurance Annual Report
Annual Report (all other entities)
Date:
Check only one:
Federal/Tax ID No.:
Contact Person:
Nevada Business ID:
Email:
(For Nevada Businesses Only)
Entity Name:
Title/Department:
Address:
Phone No.:
Fax No.:
City:
State:
Zip:
Nevada Holder Number:
Yes
No
Did your entity file a Report of Unclaimed Property with the State of Nevada last year?
If “NO,” please explain:
Prior Holder name and address:
Principal Business Activity of your Company:
State of Incorporation:
Date of Incorporation:
Parent Company Name:
Parent Company Federal/Tax ID No:
Negative Report – (no funds, shares or safekeeping). As a duly authorized representative of the holder listed above, I do hereby
certify that I have no unclaimed property to report.
Hardcopy – Paper Report (10 or fewer properties only. Reports with 11 or more properties will be returned)
Electronic Filing –CD ROM/USB (Per NAC 120A, required on reports of 11 or more properties)
SUMMARY OF PROPERTY REPORTED AND REMITTED
a. Aggregate Total – Accounts less than $50 or unknown owners
$
b. Owner Total – Accounts with funds of $50 or more
$
c. Safekeeping Total – Number of accounts remitted (Attach Safekeeping Inventory)
0.00
d. Total sum of a and b above
$
EFT (ACH/Wire Transfer) confirmation must accompany report.
Shares of Stock: Issue
CUSIP No.
Number of Shares
Were shares sent DTC? Yes No
If “Yes”, a confirmation MUST be included with the report.
Under penalty of perjury, I declare to the best of my knowledge and belief that the information provided above and in the attached schedules is
true and correct and written notice to owners, i.e. Due Diligence pursuant to NRS 120A.560, has been completed. Notarization Required.
_______________________________________
___________________________________
____________________________________
Printed Name
Signature (original signature required)
Title
State of _________________
City_________________
County_______________________
SEAL (required)
Subscribed and sworn to before me this ____________ day of ____________________ 20_____
Notary Public ________________________________________________________________________
FOR OFFICIAL USE ONLY
Check #
Check Date
Amount
Deposit #
Deposit Date
G/L Number
Receipt ID:
Report ID:
Import Batch #:
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