Form Treas 400 - Unclaimed Property Holder Report Form - 2011 Page 2
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2OWNERS OF UNCLAIMED PROPERTY
COMMONWEALTH OF KENTUCKY
Date of
Name of owner, benefi ciary,
Account Number
Property
Social Security
Amount
Amount Placed in
Last
surety, etc. (if applicable)
or Federal Tax ID
Remitted
Interest Bearing
Certifi cate Number
Code
Activity
[Last, First, Middle Initial]
(See Page 22)
Number
Accounts in 2011
Policy Number
Last Known Address
ONLY
Check Number
and/or Date of Birth
[Number & Street
City, State & Zip]
A computer printout with the required information is acceptable.
Page Total
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