Form Up-6 - Unclaimed Property Safekeeping Inventory - Nevada State Treasurer
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8Holder Name______________________
Nevada State Treasurer - Unclaimed Property
Holder FEIN_______________________
SafeKeeping Inventory
Holder ID #________________________
{*Please do NOT include any paper clips, rubber bands or obvious trash on this report.}
Clear All!
Contents of Forced Open Box or Other Repository
1. Office/Location
2. Box Number(State Code + Orig BK Loc + Box#)
Drilling
Store Address
Date Rental Due:
Annual Rental Fee:
Fee:
Original Open Date:
Lessee/Patient Name(s):
SSN or TIN [mandatory]:
Last Known Address:
Copy of Lease Agreement attached to this form
{Yes or No}
3. Reason for Forced Opening/Action:
The safe deposit box/repository contains:
Please indicate:
Contained Miscellaneous Paper Only (Stocks/Bonds/Wills/Trusts are not
considered miscellaneous paper and MUST be detailed)
or
Contained articles listed on the accompanying pages
Receipt and Release of Property
By signing below, I confirm that I have received the property described below, and that all property in the box is accounted for. I relieve The State
of responsibility for any losses I might have incurred because the property was removed from the box as required by law.
Date
Signature of Lessee/Patient/Other
Date
Signature of Lessee/Patient/Other
Signature of Legal Representative
Title (Legal Representative)
Signature of Deputy
Name of Deceased Lessee/Deputy
Form UP-6
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