Holder Verification Report - Wisconsin State Treasurer

State of Wisconsin

Holder Verification Report – 2012

Mail to: Unclaimed Property Unit, Office of the State Treasurer, 1 South Pinckney Street, Suite 360, Madison WI 53703

Holder Name

Contact Person

(PERSON MOST FAMILIAR WITH THE DETAILS OF THE REPORT)

Holder Address

Phone

e-mail

City

State

Zip

Did you file an Unclaimed Property Report with Wisconsin in 2011?

YES

Holder FEIN #

State of Incorporation

Date of Incorporation

S U M M A RY O F R E P O RT E D P R O P E RT Y

Total number of safe deposit boxes

YES

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

________________________________

(INVENTORY CONTENTS ON SAFE DEPOSIT BOX INVENTORY FORM.

DELIVER SAFE DEPOSIT BOX CONTENTS TO STATE TREASURY AFTER FEBRUARY 1, 2013)

Total number of unclaimed securities (stocks or mutual funds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __________________________________

(LIST ACCOUNTS ON UNCLAIMED SECURITIES REPORT FORM)

Total value of money remitted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

________________________________

CHECK PAYABLE TO WISCONSIN STATE TREASURY ATTACHED

ACH TRANSFER DATE ___________________

Method of reporting:

Diskette or CD

e-mail

DATE E-MAILED _____________________

Check if filing a Negative Report

(FINANCIAL INSTITUTIONS, UTILITIES, LIFE INSURANCE COMPANIES ONLY)

V E R I F I C AT I O N

State of __________________________________________________________________ County of_____________________________________________________________

I, ___________________________________________, state that I have prepared or have caused to be prepared, and have examined this report as

to property presumed abandoned under Chapter 177, Wis. Stats. I am duly authorized to execute this report on behalf of the Holder

and by law. To the best of my knowledge and belief, said report is true, correct and complete.

Signature _______________________________________________________________ Title ________________________________________________________ Date___________________________

Subscribed and sworn to before me this ___________ day of _________________________________________ , 20 ___________

Name of Notary Public _________________________________________________________ State______________________ Commission Exp. Date _________________________

F O R O F F I C E U S E O N LY

Date Received _____________________________________

Amount Received ___________________________________

Share(s) Amount __________________________________

Employee Initials ________________