Unclaimed Property Report Summary
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1UNCLAIMED PROPERTY REPORT SUMMARY
REPORT DUE DATES
ND STATE LAND DEPARTMENT
Life Insurance: May 1 (as of Dec. 31), 20____
UNCLAIMED PROPERTY DIVISION
Other Holders: Nov. 1 (as of June 30), 20____
(UPD 2005)
Contact Person and Title
Business Name and Mailing Address
(ONE BUSINESS PER REPORT SUMMARY)
(Area Code) Telephone Number
Fax Number
E-mail address
_______________________________________________________
Federal Tax ID Number (FEIN)
_______________________________________________________
If you are filing on behalf of multiple organizations, please complete a
State and Date of Incorporation
separate report for each business and/or franchise. Failure to do so
could raise compliance questions for a business that does not have its
own reporting history.
Remittance may be consolidated.
REPORTING REQUIREMENTS
Indicate your type of business in the box below. The numbers shown next to your type of business correspond with the
numbered sections on “Property Description Codes” page, which shows property types and descriptions common to
your type of business. If you need to complete an "Itemization" form, you'll need the "Property Description Codes" for
that form as well.
Bank
Fed. Savings Bank:
Utility:
Corporation:
: (1, 2, 4, 5, 10)
(1, 2, 4, 5, 10)
(1, 2, 8)
(1, 2, 6)
Credit Union:
Government:
Life Insurance:
Retail
(1, 2, 4, 5, 10)
(1, 2, 9)
(1, 2, 3)
: (1, 2)
Trust Company:
Oil/Gas Company:
Prop/Casualty Ins.
Other: ___________
(1, 2, 5)
(1, 2, 7)
(1, 2, 3)
REPORT SUMMARY
# of Items
Total $
ITEMS WITH AMOUNTS OF $50.00 AND OVER (Itemization Sheet Required)
ITEMS LESS THAN $50.00
Total Amount Due (Remit with Report)
NUMBER OF SHARES / SECURITIES BEING REPORTED
I, being duly sworn on oath, depose and say that I am the holder, or authorized to make this report for the holder; that the report on this
and attached pages, is a full, true and complete report of all unclaimed property now in possession or under the control of t his holder,
which is presumed abandoned as provided by North Dakota Century Code, Chapter 47-30.1; and that the holder sent written notice to the
owner of the property presumed abandoned as required by Section 47-30.1-17 (05), N.D.C.C.
Checks & Securities should be issued to:
______________________________________________
Signature
State Land Department
Unclaimed Property Division
PO Box 5523
Bismarck, ND 58506-5523
______________________________________________
Title
Phone: (701) 328-2800
Fax: (701) 328-3650
Date: ___________________
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Parent category: Financial