Form Upsk - Idaho Unclaimed Property - Safe Deposit Box/safekeeping Report Summary
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1Idaho Unclaimed Property
Safe Deposit Box/Safekeeping Report Summary
HOLDER INFORMATION
Date:
Federal/Tax ID No.:
En ty Name:
Contact Person:
Address:
Email:
City: State: Zip:
Title/Department:
State of Incorpora on:
Phone No.: Fax No.:
Date of Incorpora on:
Idaho Holder ID Number:
Parent Company Name:
Parent Company Federal/Tax ID No.:
SUMMARY OF PROPERTY REPORTED AND REMITTED
Number of safe deposit boxes/safekeeping items reported:
#
VERIFICATION STATEMENT
Under penalty of perjury, I declare to the best of my knowledge and belief, that the safe deposit box/safekeeping in‐
forma on provided above and in the a ached schedules is true and correct, that wri en no ce was sent to owners,
i.e., Due Diligence, pursuant to Idaho Code § 14‐517, has been completed and that I am duly authorized to execute
this verifica on by the ins tu on.
_____________________________________________
________________________________________________
Name of Authorized Officer
Signature of Authorized Officer
_____________________________________________
________________________________________________
Title of Authorized Officer
Date
UCP Receipt Date Stamp
33
UPSK (04/1713)
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