Report Of Unclaimed Safe Deposit Box Contents - 2008
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REPORT OF UNCLAIMED SAFE DEPOSIT BOX CONTENTS
PACKAGES CONTAINING WEAPONS MUST BE CLEARLY IDENTIFIED
For Department Use Only
(INITIALS)
A
Holder Name: ____________________________________________
Accept
_______
________
B
Tax ID Number: ___________________________________________
Reject
_______
________
Allowed Amounts
C
Period Covered: ________ to _______
D
Page _____ of ______
Rental Charges
_______
________
Drilling Fees
_______
________
DO NOT ATTACH TO CONTENTS
E
One Safe Deposit Box Per Page
1
Safe Deposit Box Number
5
Date of Abandonment (Month, Day, Year)
2
Owner Information
6
Branch Where Property Was Held
_________________________________________________________________________
Last
First
Middle
Branch Name
Phone #
_________________________________________________________________________
Street or PO Box
3
Social Security Number
D.O.B.
_________________________________________________________________________
City
State
Zip
4
Owner’s Mailing Address
7
Amount Due Holder
Type
Amount
Drilling . . . . . . . . . . . . . . . . . . . .$ ___________________________
Street or PO Box
Unpaid Rent . . . . . . . . . . . . . . . .$ ___________________________
Other . . . . . . . . . . . . . . . . . . . . .$ ___________________________
City
State
Zip Code
Total
$
Must show proof of expenditures.
8
Itemized Description of Contents (One Item Per Line or Attached Itemized List)
1. __________________________________________________ 7. __________________________________________________
2. __________________________________________________ 8. __________________________________________________
3. __________________________________________________ 9. __________________________________________________
4. __________________________________________________ 10. _________________________________________________
5. __________________________________________________ 11. _________________________________________________
6. __________________________________________________ 12. _________________________________________________
If you do not use this form, all of this information must be included on your itemized list.
This form may be duplicated for additional owners or if space is needed for description of contents.
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