Unclaimed Safe Deposit Box Identification Form - Wisconsin State Treasurer - 2014
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1Unclaimed Safe Deposit Box Identification Form
S TAT E O F W I S C O N S I N • O F F I C E O F T H E S TAT E T R E A S U R E R
Mail to: Unclaimed Property Unit, Office of the State Treasurer, 1 South Pinckney Street, Suite 360, Madison WI 53703
A
C
Holder Name:
Report Year:
D
B
Tax ID Number:
Safe Deposit Box Number:
E
H
Owner(s) Information
Branch Where Property Was Held
LAST NAME
LAST NAME
BRANCH NAME
FIRST NAME
MIDDLE
FIRST NAME
MIDDLE
STREET OR PO BOX
SOCIAL SECURITY #
SOCIAL SECURITY #
CITY
STATE
ZIP CODE
F
I
Owner’s Mailing Address
Amount Due Holder
STREET OR PO BOX
TYPE
AMOUNT
Drilling .................................................................$ ________________________
CITY
STATE
ZIP CODE
Unpaid Rent .........................................................$ ________________________
G
Date of Abandonment
Other ..................................................................$ ________________________
MONTH, DAY, YEAR
_______________________
TOTAL $
CHECKLIST TO REPORT SAFE DEPOSIT BOX CONTENTS
1. Official bank inventory in contents envelope.
2. Unclaimed Safe Deposit Box Identification Form completed and attached to OUTSIDE of contents envelope.
3. Deliver to State Treasury during the period of February 1– 15, 2014.
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Parent category: Financial