Unclaimed Nclaimed Property - Reporting Booklet - Washington Department Of Revenue Page 8
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28State of Washington
Department of Revenue
Unclaimed Property Section
S
UMMARY
R
EPORT
F
OR
U
NCLAIMED
P
ROPERTY
PO Box 448
Olympia, WA 98507-0448
(360) 586-2736
Report And Payment Due By November 1.
Federal ID Number:
Report Year:
Date & State of Incorporation:
SIC Code:
Place Address Label Here
Primary Business Activity:
Name and Address Corrections:
Contact Person:
(
)
Name
Telephone Number
E Mail Address
Check here if you have Nothing To Report and complete the declaration below.
Final Report: Please close my account (attach explanation).
Reporting Media - Circle all media used and provide report totals.
Cash
Shares
Number of Items
Diskette *................................................
$
Magnetic Tape/Cartridge........................
$
Paper.......................................................
$
* Indicate total number of diskettes submitted if reporting by this method
.
Summarize below types of property being reported.
Category Code
Amount
Category Code
Amount
$
$
$
$
$
$
Report Declaration:
I declare that this report, including accompanying statements, has been examined by me; that I am duly authorized by the holder
herein to execute this report, and that I believe said report is true, correct and complete for the stated period.
Mailing Address:
Department of Revenue
Signature
Unclaimed Property Section
PO Box 448
Title
Olympia, WA 98507-0448
Mail this form with your report (paper, tape or diskette) and
Date
remittance by November 1.
Report Type
Remittance Status Code
Report Year
1 Annual
1 Reported Only
Remitted Amount
$
2 Field Audit
2 Remitted
3 File Audit
Check/Receipt No.
3 Negative Report
4 Vendor Audit
4 Zero Remittance
Date Received
5 ER
6
Owner Records Added
Interest Penalty
To inquire about the availability of this form in an alternate format for the visually impaired, please call (360) 753-3217. Teletype
Unclaimed Property Reporting Booklet
(TTY) users please call (800) 451-7985. You may also access information on our Internet home page at
REV 80 0004-1 (8-3-01)
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