Form St77 - Report Of Unclaimed Property - 2016

(ST77)

R

U

P

EPORT OF

NCLAIMED

ROPERTY

F

Y

E

D

31, 2016

OR THE

EAR

NDING

ECEMBER

THIS FORM MAY ONLY BE USED TO REPORT 3 OR LESS PROPERTIES

ALL OTHER HOLDERS MUST FILE ELECTRONICALLY

Holder Name:

State of Connecticut

Office of the State Treasurer

Holder Tax ID#:

Unclaimed Property Division

Holder Address:

PO Box 150435

____________________________________________________________

Hartford, CT 06115-0435

____________________________________________________________

File Originals with your remittance on or before March 31, 2017

Contact Name:

State of ___________________________ County of __________________________

Contact phone:

Contact Email:

I, _______________________________________ (person signing the form) being first duly sworn, on oath depose and state that I have caused to be prepared and have examined this

report hereto totaling $______________, # of shares_______________, and # of properties ___________ as to property presumed abandoned under Connecticut Unclaimed Property Law

for the year ending as stated above. I am duly authorized to execute this verification on behalf of the holder. I ascertain that due diligence requirements have been adhered to prior to

presumption of abandonment and completion of this report, and I believe that said report is true, correct, and complete as of said date.

Signature: _______________________________________

Title: _______________________________ Notary Signature (and Seal): ____________________________

Type or Print Neatly Using Black Ink

Date of Last

Transaction or Date

NAUPA

property became

CODE #

Payable,

Total $

Owner’s Last Name, First name, Initial, Last Known Street Address, City, State, Zipcode

Owner’s Social

(Property

Redeemable or

Remitted and

Code)

(List Alphabetically by last name)

Security Number

returnable

Due Owner

(1)

(2)

(3)

(4)

(5)

Total:

Form ST77

Revised: October 2016