Form Asd-159g - Unclaimed Property Verification And Checklist - State Of North Carolina - 2012
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1State of North Carolina Form ASD-159G
State of North Carolina
State of North Carolina
North Carolina Department of State Treasurer
Department of State Treasurer
Unclaimed Property Verification and Checklist
Unclaimed Property and Escheats Division
Unclaimed Property Division
Unclaimed Property Verification and Checklist
Janet Cowell, State Treasurer
325 North Salisbury Street
Governmental Agencies ONLY
Raleigh, North Carolina 27603-1385
Reporting Period July 1, 2011 through June 30, 2012
(919)508-1000
325 North Salisbury Street Raleigh, North Carolina 27603-1385
All Non-Life Insurance Holders
Due November 1, 2012
Tel: (919)508-1000 Web:
HOLDER ID# (If Known)
HOLDER ID# (If Known)
HOLDER NAME
HOLDER NAME
DATE OF INCORPORATION
DATE OF INCORPORATION
MAILING ADDRESS
MAILING ADDRESS
CITY
CITY
STATE
STATE
ZIP CODE
ZIP CODE
CONTACT PHONE
CONTACT PHONE
STATE OF INCORPORATION
STATE OF INCORPORATION
NUMBER OF EMPLOYEES
NUMBER OF EMPLOYEES
E-MAIL ADDRESS
E-MAIL ADDRESS
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FEDERAL IDENTIFICATION NUMBER
FEDERAL IDENTIFICATION NUMBER
Every person, corporation, or other business association, banking or financial organization, insurance company, utility, court or public authority,
Every person, corporation, or other business association, banking or financial organization, insurance company, utility, court or public authority,
etc. reporting unclaimed property must complete this form (ASD-159) and it should be filed with the Annual Report of Unclaimed Property
etc. reporting unclaimed property must complete this form (ASD-159) and it should be filed with the Annual Report of Unclaimed Property
(ASD-21) and/or Report of Unclaimed Securities (ASD-215) and/or Abandoned Tangible Personal Property (ASD-127). This checklist includes,
(ASD-21) and/or Report of Unclaimed Securities (ASD-215) and/or Abandoned Tangible Personal Property (ASD-127). This checklist includes,
but is not limited to those items that are covered by the North Carolina Escheat and Unclaimed Property Law, North Carolina General Statute
but is not limited to those items that are covered by the North Carolina Escheat and Unclaimed Property Law, North Carolina General Statute
116B.
116B.
LATE FILING INTEREST PENALTY
LATE FILING INTEREST PENALTY
In addition to any other penalties, any holder who files after November 1, shall remit interest at the rate pursuant to North Carolina General
In addition to any other penalties, any holder who files after November 1, shall remit interest at the rate pursuant to North Carolina General
Statute 116B-77, currently 5%. The interest penalty is computed as follows:
Statute 116B-77, currently 5%. The interest penalty is computed as follows:
Total amount of property reportable X # of days late/365 X 5%= Interest Penalty.
Total amount of property reportable X # of days late/365 X 5%= Interest Penalty.
CERTIFICATION AND VERIFICATION
CERTIFICATION AND VERIFICATION
As the person authorized to bind this holder, I, being duly sworn, certify the attached report to be true and properly prepared and
As the person authorized to bind this holder, I, being duly sworn, certify the attached report to be true and properly prepared and
examined for correctness, ensuring that all property eligible to be remitted is included in this return, and the property reported has
examined for correctness, ensuring that all property eligible to be remitted is included in this return, and the property reported has
been held for the period required by North Carolina General Statute 116B-53. Further, I certify that notices pursuant to North Carolina
been held for the period required by North Carolina General Statute 116B-53. Further, I certify that notices pursuant to North Carolina
General Statute 116B-59 were sent to the owners at their last known address. This notarized certification is an affidavit attesting that
General Statute 116B-59 were sent to the owners at their last known address. This notarized certification is an affidavit attesting that
the holder has complied with North Carolina General Statute 116B-59.
the holder has complied with North Carolina General Statute 116B-59.
REPORT TOTAL:
REPORT TOTAL:
NAME-PRINT:
NAME-PRINT:
INTEREST PENALTY:
INTEREST PENALTY:
TITLE:
TITLE:
TOTAL REMITTANCE:
TOTAL REMITTANCE:
SIGNATURE:
SIGNATURE:
TOTAL SHARES:
TOTAL SHARES:
NOTARY PUBLIC CERTIFICATION
NOTARY PUBLIC CERTIFICATION
State of_______________________________,County of_________________________________
State of_______________________________,County of_________________________________
SEAL
SEAL
I,___________________________,a notary public for said county, do hereby certify that__________________________
I,___________________________,a notary public for said county, do hereby certify that__________________________
personally appeared before me this date and acknowledged the due execution of the foregoing instrument. Witness my
personally appeared before me this date and acknowledged the due execution of the foregoing instrument. Witness my
hand and official seal this_____________ day of_________________,20______
hand and official seal this_____________ day of_________________,20______
My Commission expires:___________________________20_________
My Commission expires:___________________________20_________
Signature of Notary____________________________________________
Signature of Notary____________________________________________
FOR OFFICE USE ONLY
FOR OFFICE USE ONLY
CD OR DISKETTE
CD OR DISKETTE
REPORT IMPORT #
REPORT IMPORT #
LOADED
LOADED
KEYED
KEYED
BALANCED
BALANCED
COMMITED
COMMITED
RECEIPT ID
RECEIPT ID
STOCK ID
STOCK ID
CUSIP
CUSIP
SYMBOL
SYMBOL
CERTIFICATE
CERTIFICATE
DTC
DTC
DATE
DATE
CUSTODIAN
CUSTODIAN
REV 07/2012
ASD-159G
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