Form St77 - Report Of Unclaimed Property - 2011

(ST77)

R

U

P

EPORT OF

NCLAIMED

ROPERTY

F

Y

E

D

31, 2011

OR THE

EAR

NDING

ECEMBER

THIS FORM MAY ONLY BE USED TO REPORT 3 OR LESS PROPERTIES

ALL OTHER HOLDERS MUST FILE ELECTRONICALLY

Holder Name:

State of Connecticut

Holder Tax ID#:

Office of the State Treasurer

Unclaimed Property Division

Address:

th

55 Elm Street, 5

Floor

____________________________________________________________

____________________________________________________________

Hartford, CT 06106

____________________________________________________________

File Originals with your remittance on or before March 30, 2012

St. of Incorporation:

Contact Name:

State of ___________________________ County of __________________________

Contact phone:

Contact Email:

I, _______________________________________ being first duly sworn, on oath depose and state that I have caused to be prepared and have examined this report hereto totaling

$______________, # of shares_______________ and # of properties ___________ as to property presumed abandoned under Connecticut Unclaimed Property Law for the year ending as

stated above. I am duly authorized to execute this verification on behalf of the holder; I ascertain that due diligence requirements have been adhered to prior to presumption of

abandonment and completion of this report, and I believe that said report is true, correct and complete as of said date.

Signature: _______________________________________

Title: _______________________________ Notary Signature (and Seal): ____________________________

Type or Print Neatly Using Black Ink

Date of Last

Transaction or Date

NAUPA

property became

CODE #

Payable,

Owner’s Last Name, First name, Initial, Last Known Street Address, City, State, Zipcode

Owner’s Social

(Property

Redeemable or

Total Remitted

Code)

(List Alphabetically by last name)

Security Number

returnable

and Due Owner

(1)

(2)

(3)

(4)

(5)

Total:

Form ST77

Revised: December 2011