Unclaimed Property Annual Compliance Report Cover Sheet
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1
2Office of the Vermont State Treasurer – Unclaimed Property Division
th
109 State St., 4
Floor • Montpelier, VT 05609-6200 │ Phone: 802.828.2407 • Fax: 802.828.2884
tre.upcompliance@vermont.gov
U
P
A
C
R
C
S
NCLAIMED
ROPERTY
NNUAL
OMPLIANCE
EPORT
OVER
HEET
(This Sheet MUST Accompany Report)
Submission Date
HOLDER NAME
R
D
D
: M
1, 20
R
P
: J
. 1, 20
D
. 31, 20
EPORT
UE
ATE
AY
EPORTING
ERIOD
AN
TO
EC
1. Federal ID No.
Contact Person
Title
Address
E-mail Address
City
Telephone
State
Zip
State of Incorporation
Date of Incorporation
If a successor to a previous holder of the property, or if your organization name changed, indicate original holder name and
P
H
REVIOUS
OLDER NAME
address – or name and address under which your organization previously filed unclaimed property reports in Vermont.
Name
Address
☐
☐
☐
☐
Characteristic Applicable to Business
Total Assets
Premiums Written
Yearly Deposits
Sales/Gross Receipts
$0 – 10
$51 – 100
☐
☐
☐
☐
☐
Range (millions)
$11 - 25
$26 - 50
$101+
☐
☐
☐
☐
☐
☐
☐
Employees
1 - 20
21 - 50
51 - 100
101 - 250
251 - 500
501 - 900
901+
☐
☐
2.
Was an unclaimed property report filed last year for this holder?
Yes
No
If No, please explain:
☐
☐
2A.
Was a negative unclaimed property report filed last year for this holder?
Yes
No
3.
Summary classification of property being reported/remitted:
T
OTALS
A.
Accounts equal to $25 or less (
$
# OF ACCOUNTS WITHIN AGGREGATE TOTAL)
B.
Accounts more than $25 (owner name is unknown)
$
C.
Accounts more than $25 (owner name is known)
$
TOTAL FINANCIAL PROPERTY REMITTED (all accounts)
$
D.
Total SHARE(s) Remitted
Affidavit of Due Diligence
Safe Deposit Box Details
Estimated Delivery Date
The undersigned (print name)
declares that the Due Diligence mailing was performed in accordance with §1247(g)
Quantity of Boxes to be
V.S.A. Title 27, Chapter 14 on
accounts.
(enter number of letters mailed)
Delivered
Signature
Title
The undersigned, (print name)
, being duly sworn on oath, deposes and says that he/she has caused
to be prepared and has examined this report of
pages, totaling
$
, as to property presumed abandoned under the
Vermont Statutes Annotated, Title 27, Chapter 14, for the year ending as stated and that he/she, acting as duly authorized representative of
, declares, in accordance with Title 13, Chapter 67, Section 3016 ‘False Claims’, that,
to the best of his/her knowledge and belief, said report is a true and complete statement of all abandoned property held or owing by the HOLDER
at the close of business on this date, except such items as have since said date ceased to be abandoned.
Print Name
Signature
Title
Subscribed and sworn before me on this
day of
, in the year
NOTARY:
M
C
Y
OMMISSION
E
:
XPIRES
FOR UNCLAIMED PROPERTY DIVISION USE ONLY
Holder ID/Year/Suffix
Check Amount
Deposit Date
Balanced By
Holder Label
Mail to: 109 State St., 4th Floor │ Montpelier, VT 05609-6200
Make check payable to: Vermont State Treasurer's Office
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