Form 496-Up - Report Of Unclaimed Report - Verification And Checklist - 2017 Page 2
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2Safe Deposit Boxes and Safekeeping
___ ___ SD01
Safe Deposit Box Contents
5
___ ___
SD03
Other Tangible Property
5
___ ___ SD02
Other Safekeeping
5
Securities
___ ___ SC01
Dividends
3
___ ___
SC13
Funds for Liquidation/Redemption
3
___ ___ SC02
Interest (Bond Coupons)
3
of Un-surrendered Stocks or Bonds
___ ___ SC03
Principal Payments
3
___ ___
SC14
Debentures
3
___ ___ SC04
Equity Payments
3
___ ___
SC15
US Government Securities
5
___ ___ SC05
Profits
3
___ ___
SC16
Mutual Fund Shares
3
___ ___ SC06
Funds Paid to Purchase Shares
3
___ ___
SC17
Warrants (Rights)
3
___ ___ SC07
Funds for Stocks and Bonds
3
___ ___
SC18
Matured Bond Principal
3
___ ___ SC08
Shares of Stock Returned by Post Office
3
___ ___
SC19
Dividend Reinvestment Plans
3
___ ___ SC09
Cash for Fractional Shares
3
___ ___
SC20
Credit Balances
3
___ ___ SC10
Un-exchanged Stock of Successor Corp
3
___ ___
SC21
Common Stock
3
___ ___ SC11
Other Certificates of Ownership
3
___ ___
SC22
Convertible Securities
3
___ ___ SC12
Underlying Shares or Other
3
___ ___
SC23
Preferred Securities
3
Outstanding Certificates
___ ___
SC24
Fixed Income Securities
3
___ ___
SC25
Real Estate-Based Securities
3
Trust, Investment, and Escrow Accounts
___ ___ TR01
Paying Agent Accounts
5
___ ___
TR04
Escrow Accounts
5
___ ___ TR02
Undelivered or Uncashed Dividends
5
___ ___
TR05
Trust Vouchers
5
___ ___ TR03
Funds Held in Fiduciary Capacity
7
___ ___
TR99
Aggregate Trust Property
5
Uncashed Checks
___ ___ CK01
Cashier’s Checks
5
___ ___
CK10
Expense Checks
5
___ ___ CK02
Certified Checks
5
___ ___
CK11
Pension Checks
5
___ ___ CK03
Registered Checks
5
___ ___
CK12
Credit Checks or Memos
5
___ ___ CK04
Treasurer’s Checks
5
___ ___
CK13
Vendor Checks
5
___ ___ CK05
Drafts
5
___ ___
CK14
Checks Written Off to Income
5
___ ___ CK06
Warrants
5
___ ___
CK15
Other Outstanding Official Checks
5
___ ___ CK07
Money Orders
7
___ ___
CK16
CD Interest Checks
5
___ ___ CK08
Traveler’s Checks
15
___ ___
CK99
Aggregate Uncashed Checks
5
___ ___ CK09
Foreign Exchange Checks
5
Utilities
___ ___ UT01
Utility Deposits
1
___ ___
UT04
Capital Credit Distribution
5
___ ___ UT02
Membership Fees
1
___ ___
UT99
Aggregate Utility Property
1
___ ___ UT03
Refunds or Rebates
1
Please indicate the primary business activity of your company ________________________________________________________________________
Did you file a report of unclaimed property last year: YES ______ NO ______ If no, please explain: _______________________________________
Holder Contact: ___________________________________________________________________ Telephone Number: ________________________
Claim Person: ___________________________________________________________________ Telephone Number: ________________________
Address:__________________________________________________________________________________________________________________
State of ___________________________________________________:
County of _________________________________________________: SS
I, _________________________________________________________________, being first duly sworn, on oath depose and state that I have caused to be prepared
and have examined this report consisting of ________ pages totaling $ ____________, ______________ shares, and ____________ safekeeping items as to property
presumed abandoned under the Oklahoma Unclaimed Property Law for the year ending as stated, that I am duly authorized to execute this verification by the holder
and by law and that I believe that said report is true, correct and complete as of said date, excepting for such property as has since ceased to be abandoned.
Signature ________________________________________________________________ Title _________________________________________________
Subscribed and sworn to before this _______________ day of ___________________________, _________________.
Notary Signature: _________________________________________________________________________________
My Commission Expires the __________________ day of _____________________________, _________________.
Mail reports and make checks payable to:
Oklahoma State Treasurer
Unclaimed Property Division
2300 N Lincoln Blvd., Rm. 217
Oklahoma City, Oklahoma 73105-4895
Reporting: (405) 521-4275
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