Form 04-720a - Verification For Unclaimed Property

Department of Revenue

ALASKA DEPARTMENT OF REVENUE

Treasury Division

DUE BEFORE

PO Box 110405

VERIFICATION FOR UNCLAIMED PROPERTY

NOVEMBER 1

Juneau, AK 99811-0405

FORM 04-720A

Voice: (907) 465-3726 GOLDPAN

Fax: (907) 465-2394

Federal EIN

Report Year Ending

Period Covered

HOLDER INFORMATION

Company Name (not agent or reporting service name)

Business Name

Mailing Address

City, State Zip Code

State of Incorporation

Date Incorporated

Contact Person

Contact Telephone Number

Address (if different from above)

Contact E-Mail Address

Fax Number

Holder Type:

 Bank

 Credit Union

 Government, State, Local, Federal

 Health Care Facility

 Hospitals

 Insurance Company - Casualty

 Insurance Company - Life & Casualty

 Insurance Company - Life

 Manufacturer

 Mutual Fund

 Oil and Gas

 Retail

 Safe Deposit Company

 Savings and Loan

 Schools and Colleges

 Trust Company

 Utility



Other ________________________

CHANGE OF HOLDER INFORMATION (List former name, address or federal EIN)

Date of Change

Former Name

Former Address

Former Federal EIN

******* YOU MUST CHECK THE REMITTANCE BOX BELOW*******

Alaska Unclaimed Property Program

Check Enclosed

EFT or Wire Transfer

REMIT TO:

Book Entry Shares

Total Amount of Unclaimed

Total Shares Remitted

Number of

DRP Shares

Properties:

Property Reported & Remitted:

Depository Trust Corp:

Mutual Fund Shares

* * *

REMITTANCE AND/OR SECURTITY TRANSFERS MUST ACCOMPANY REPORT * * *

Note: The verification, if made by a partnership, shall be executed by a partner. If made by an unincorporated association or private corporation, by an officer;

and if made by a public corporation, the chief financial officer.

Sec. 11.56.210. Unsworn falsification in the second degree.

(a) A person commits the crime of unsworn falsification in the second degree if, with the intent to mislead a public servant in the performance of a duty, the

person submits a false written or recorded statement that the person does not believe to be true

(1) in an application for a benefit; or

(2) on a form bearing notice, authorized by law, that false statements made in it are punishable.

Unsworn Falsification Statement

I acknowledge and affirm under penalty of perjury UNSWORN FALSIFICATION (AS 11.56.210); (i) that I have prepared, or have caused to be prepared and have

examined this report; (ii) that this report is true, correct, and complete; (iii) that I have the authority to verify this report on behalf of my organization to report and

transfer unclaimed property to the state; and (iv) that it is agreed that any and all transactions entered into by my organization in connection with the reporting and

transfer of unclaimed property to the state, will be subject to (a) the Uniform Electronic Transactions Act (UETA) to the extent applicable under applicable state law,

and (b) the federal electronic signatures in Global and National Commerce Act (E-SSIGN), with the effect that keying in our names or attaching facsimilie signatures

to electronic documents indicates our intention that they be deemed to be binding electronic signatures.

Signature

Printed Name

Title

Date

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Form 04-720A (Rev 08/2014)