Form Asd-21 - Report Of Unclaimed Property - North Carolina Department Of State Treasurer

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North Carolina Department of State Treasurer
Name of Holder:
REPORT OF UNCLAIMED PROPERTY
* LIFE INSURERS ONLY - Reporting Period January 1, 2011 through December 31, 2011.
Due May 1, 2012
Holder #:
Federal ID#:
Page(s):
_______ of _______
* ALL HOLDERS EXCEPT LIFE INSURERS - Reporting Period July 1, 2010 through June
30, 2011. Due November 1, 2011
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
Date of Last
If Joint
Transaction or
Owner,
Statutory Reductions
Owner(s)
Owner(s) Social
Property
Date Property
Beneficiary,
Owner(s) Identifier
Net Amount
(See Back)
Owner(s) Last Name(s) Owner(s) First Name(s)
Middle
Suffix
Street
City
State
Zip
Security
Class
Became
Trustee, Etc.,
Number(s)
Remitted
Initial(s)
Number(s)
Code
Payable,
Specify By
Redemable or
Name
Returnable
Type
Amount
TOTAL THIS PAGE
$
REPORT TOTAL
$
If this is the last page of report, enter total to be remitted &
carry over to ASD-159
Form: ASD-21
Revised 06/16/11

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