Form Up-12 - Unclaimed Property Sale Or Re-Registration Of Stock

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STATE OF NEW JERSEY
UP-12
DEPARTMENT OF THE TREASURY
10-95, R-2
UNCLAIMED PROPERTY
SALE OR RE-REGISTRATION OF STOCK
Sale or Re-Registration # __________________________
Claim #___________________________
Registered in Name(s) of: . . . . . . . . . . . . . . . . . ._________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Current Address: . . . . . . . . . . . . . . . . . . . . . . . _________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Social Security Number(s) . . . . . . . . . . . . . . . __________ / _______ / __________
__________ / _______ / __________
__________ / _______ / __________
__________ / _______ / __________
Holder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
_________________________________________ Report Year________________
Report Date Paid - if different . . . . . . . . . . . .
_________________________________________________________________________
Original Shares:
Original Dividends . . . . . . . . . . . . . . ________________________
Plus Interest . . . . . . . . . . . . . . . . . . . ________________________
Security ________________________# Shares______________
Other cash assoc. with original property ________________________
Security ________________________# Shares______________
Plus Interest . . . . . . . . . . . . . . . . . . . ________________________
Assoc. Divs. . . . . . . . . . . . . . . . . . . . ________________________
Security ________________________# Shares______________
Plus Interest . . . . . . . . . . . . . . . . . . . ________________________
Security ________________________# Shares______________
Fractional Shares . . . . . . . . . . . . . . . . ________________________
Security ________________________# Shares______________
Plus Interest . . . . . . . . . . . . . . . . . . . ________________________
Other Cash Prop . . . . . . . . . . . . . . . . ________________________
Security ________________________# Shares______________
Plus Interest . . . . . . . . . . . . . . . . . . . ________________________
Security ________________________# Shares______________
Proceeds from Liquidation . . . . . . . . ________________________
Plus Interest . . . . . . . . . . . . . . . . . . . ________________________
Security ________________________# Shares______________
Proceeds from Sale of Stock . . . . . . . ________________________
Corp. Actions:
Splits
Mergers
Spinoffs
Liquidation
(see below)
TOTAL CASH . . . . . . . . . . . . . . . . .
Re-register as follows:
Security_______________________________________________
# Shares . . . . . . . . . . . . . . . . . . . . . . _______________________
Security_______________________________________________
# Shares . . . . . . . . . . . . . . . . . . . . . . _______________________
Security_______________________________________________
# Shares . . . . . . . . . . . . . . . . . . . . . . _______________________
Security_______________________________________________
# Shares . . . . . . . . . . . . . . . . . . . . . . _______________________
Security_______________________________________________
# Shares . . . . . . . . . . . . . . . . . . . . . . _______________________
Security_______________________________________________
# Shares . . . . . . . . . . . . . . . . . . . . . . _______________________
Security_______________________________________________
# Shares . . . . . . . . . . . . . . . . . . . . . . _______________________
Security_______________________________________________
# Shares . . . . . . . . . . . . . . . . . . . . . . _______________________

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