Form Up-3k - Individual Safe Deposit Box Certificate Of Inventory - 2012
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1UP-3K(Rev. 06/2012)
GEORGIA DEPARTMENT OF REVENUE
UNCLAIMED PROPERTY PROGRAM
INDIVIDUAL SAFE DEPOSIT BOX
CERTIFICATE OF INVENTORY
FORM UP-3K
2012
HOLDER ID
FEIN
NO.
REPORT DATE
FINANCIAL CENTER NAME AND ADDRESS
(2)
(3)
(4)
(1)
SAFE DEPOSIT BOX
RELATIONSHIP
RENTER’S NAME AND ADDRESS
DRILL DATE
CODE
NUMBER
(5)
(7)
(8)
(6)
On the above drill date, after notice, and in accordance with state law and the rules and regulations of
(FINANCIAL INSTITUTION)
_______________ , and in agreement entered into with the Renter, this financial institution in the presence of the undersigned
officer and the undersigned Notary Public caused said Safe Deposit Box to be drilled and the contents thereof removed and
inventoried as follows:
SAFE-
NO. OF
KEEPING
ITEMS
CODE
DESCRIPTION
(11)
(9)
(10)
Annual Rent ______________
Drilling Fee _______________
Total _______________
I certify that the items for box number __________ as listed above represent the entire contents of this box on the cited drilling
date. The contents listed above have been securely wrapped, and the package plainly marked per Submission Instructions for
Safekeeping Items.
Signed _______________________________________
Title _________________________________________
Signed _______________________________________
(Notary Public)
- Notary Seal -
My Commission Expires: _________________________
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