State of Wisconsin
Holder Verification Report – 2010
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, PO Box 2114, Madison WI 53701-2114
A
C
Holder Name
Contact Person
(PERSON MOST FAMILIAR WITH THE DETAILS OF THE REPORT)
Holder Address
Phone
e-mail
City
State
Zip
D
Did you file an Unclaimed Property Report with Wisconsin in 2009?
YES
NO
B
Holder FEIN #
E
State of Incorporation
Date of Incorporation
S U M M A RY O F R E P O RT E D P R O P E RT Y
#
F
Total number of safe deposit boxes
YES
NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
________________________________
(INVENTORY CONTENTS ON SAFE DEPOSIT BOX INVENTORY FORM.
DELIVER SAFE DEPOSIT BOX CONTENTS TO STATE TREASURY AFTER FEBRUARY 1, 2011)
G
Total number of unclaimed securities (stocks or mutual funds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __________________________________
(LIST ACCOUNTS ON UNCLAIMED SECURITIES REPORT FORM)
$
H
Total value of money remitted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
________________________________
CHECK PAYABLE TO WISCONSIN STATE TREASURY ATTACHED
ACH TRANSFER DATE ___________________
I
Method of reporting:
Diskette or CD
e-mail
Paper
ATTACHED
DATE E-MAILED _____________________
MAILED SEPARATE
Check if filing a Negative Report
(FINANCIAL INSTITUTIONS, UTILITIES, LIFE INSURANCE COMPANIES ONLY)
V E R I F I C AT I O N
J
State of __________________________________________________________________ County of_____________________________________________________________
I, ___________________________________________, state that I have prepared or have caused to be prepared, and have examined this report as
to property presumed abandoned under Chapter 177, Wis. Stats. I am duly authorized to execute this report on behalf of the Holder
and by law. To the best of my knowledge and belief, said report is true, correct and complete.
Signature _______________________________________________________________ Title ________________________________________________________ Date___________________________
Subscribed and sworn to before me this ___________ day of _________________________________________ , 20 ___________
Name of Notary Public _________________________________________________________ State______________________ Commission Exp. Date _________________________
F O R O F F I C E U S E O N LY
Date Received ____________________
Amount Received ________________________
Check #__________________
Cert #_______________________
Share(s) Amount _____________________________
Employee Initials ________________
10