Form 04-720.a - Verification For Unclaimed Property - Alaska Department Of Revenue
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1Department of Revenue
ALASKA DEPARTMENT OF REVENUE
DUE DATE
Treasury Division
November 1
PO Box 110405
VERIFICATION FOR UNCLAIMED PROPERTY
Juneau, AK 99811-0405
Voice: (907) 465-3726
Instructions: Complete this form and attach it to Form 04-720B
Fax: (907) 465-2394
Report of Unclaimed Property: Mail your report and remittance on or before November 1.
This form is available online at
Federal EIN
Report Year Ending
Period Covered
HOLDER INFORMATION
Company Name (not agent or reporting service name)
Business Name
Address
City, State Zip Code
Holder ID #, If Known
State of Incorporation
Date Incorporated
Contact Person
Contact Telephone Number
Address (if different from above)
E-Mail Address
Fax Number
Holder Type:
Bank
Credit Union
Government, State, Local, Federal
Health Care Facility
Hospitals
Insurance Company:Casualty
Insurance Company - Life & Casualty
Insurance Company - Life
Manufacturer
Mutual Fund
Oil and Gas
Retail
Safe Deposit Company
Savings and Loan
Schools and Colleges
Trust Company
Utility
Other
CHANGE OF HOLDER INFORMATION (List former name, address or federal EIN)
Date of Change
Former Name
Former Address
Former Federal EIN
AGENT INFORMATION (If filed by agent, complete the following)
Agent Name
Contact Name & Phone Number
Agent Federal EIN
REMITTANCE
Total Amount Remitted (included with report)
Total Shares Remitted (with report)
Total Shares Remitted (Depository Trust Corp.)
* * *
YOUR REMITTANCE MUST ACCOMPANY REPORT
* * *
State (Province) of __________________________________:SS
I, _________________________________, being first duly sworn, on oath depose and state that I have cause to be prepared and have
examined this report consisting of __________ pages totaling $ ________________ as to property presumed abandoned under the Alaska
Unclaimed Property Act for the year ending as stated; that I am duly authorized by the holder herein to execute this report; and that I
believe said report is true, correct and complete as of said date, excepting for such property as has since ceased to be abandoned.
Signature
Printed Name
Title
Subscribed and Sworn to me before this ________ day of _____________________ in the year ________________
Signature
Printed Name
Notary Public For:
My Commission expires:
Note: The verification, if made by a partnership, shall be
executed by a partner. If made by an unincorporated
association or private corporation, by an officer; and if made
by a public corporation, the chief financial officer.
(Please read General Information and Instructions)
Form 04-720.A (Rev 01/01)
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