Form Treas 400 - Unclaimed Property Holder Report Form - 2011
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TREAS 400
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CURRENT HOLDER NAME & ADDRESS:
________________________________________
FEIN#: ____-_____________________________
________________________________________
CONTACT_______________________________
________________________________________
TEL.#___________________________________
________________________________________
E-MAIL__________________________________
State of Incorporation ______ Date of Inc. ___________
DO YOU NEED MORE TIME? (SEE PAGE 18)
If holder name has changed show the previous name here: ________________________________________
………………………………………………………………………………………………………………………………..
INFORMATION ABOUT PROPERTY YOU ARE HOLDING
1. Total value of property placed in interest bearing accounts in 2011. . . . . . . ……$ ___________________
DO NOT INCLUDE 2001 REPORTS (financial institutions only, see page 7)
2. Total number of unclaimed stock shares being reported …………………….....________________________
3. Number of unclaimed safe deposit boxes being reported……………………..…________________________
Submit list of contents on
.
CD/Rom
DO NOT ATTACH SAFE DEPOSIT BOX CONTENTS TO THIS REPORT
4. Total value of accounts being remitted……………………………………………….. $_____________________
Attach check & stock statements to this holder report. Make check payable to: Kentucky State Treasurer
More than 10 properties must be reported on CD/Rom … (See Page 6)
…………………………………………………………………………………………………………………………………
Read page 17 before signing affidavit
VERIFICATION
I, ________________________________, swear that I have prepared, or have caused to be prepared, and
have examined this report as to property presumed abandoned under KRS 393 and other applicable state
laws. I am duly authorized to execute this verification by the holder and by law. To the best of my knowledge
and belief, said report is true, correct, and complete.
Signature _______________________________ Title ___________________________ Date ____________
OFFICIAL USE ONLY
CK attached (y n) Amt.___________________ CD/Rom attached (y n)
Invoice Attached (y n)
SDB reported (y n)
Stocks (y n) Date__/__/___
Cust______________
Receipt # _____________________ Report ID# _____________________ Staff________ Date__/__/__
CR#
KENTUCKY DEPARTMENT OF TREASURY
UNCLAIMED PROPERTY DIVISION
1050 US HWY. 127 S., SUITE 100, FRANKFORT, KY 40601
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