Form St-2 - Report Of Unclaimed Property - Verification And Checklist printable pdf download

UTAH STATE TREASURER

UNCLAIMED PROPERTY DIVISION

341 South Main Street, 5

Floor

Salt Lake City, Utah 84111

Telephone: (801) 320-5360

FAX: (801) 533-4096

Toll Free (888) 217-1203

Email:

holders@utah.gov

REPORT OF UNCLAIMED PROPERTY – VERIFICATION AND CHECKLIST

To be filed as part of your Annual Report of Unclaimed

Property. Verification for Period Ending June 30,

_______________

Federal Tax Identification Number______________________________

State of Incorporation________________________________________

Date of Incorporation________________________________________

Number of Utah Employees__________________________________

Please make correction to label if address or company name has changed.

Primary business activity____________________________________

Person completing report _____________________________________Phone: ( ) _______________Email _________________________

Address, if different than above ________________________________________________________________________________________

Claims Contact Person _______________________________________Phone: ( ) _______________Email _________________________

Did you file a report of unclaimed property last year?

______yes _____no (if no, date of last report) _____________________________

If you are a successor to a previous holder of the property, or if you have changed your name, please list prior name below and show the year in which the

change became effective.

If your report includes property held by subsidiary companies, list the name(s) of those companies.

Every person, corporation, business association, banking or financial organization, life insurance corporation, utility, court or public authority must complete

the Verification and Checklist before filing their Utah Unclaimed Property Report. The list includes (by way of illustration, but not limitation) those items

which are covered by UCA, Section 67-4a-101 et.seq. (2007).

Under penalty of perjury, I ,__________________________________________________________________state that I have examined this report having

a value totaling $ ________________and ______________________shares as to property presumed abandoned under the Utah Unclaimed Property Law for

the year ending as stated, that I am duly authorized to execute the Verification and Checklist of the Annual Report and that I believe that the said report is true,

correct and complete to the best of my knowledge.

Signature: _________________________________________

Title: _____________________________________________

Dated: ____________________________________________

Checklist must be completed

YOUR REMITTANCE MUST ACCOMPANY REPORT

Utah State Treasurer

Mail report To:

Unclaimed Property Division

341 South Main Street, 5

Floor

Salt Lake City, Utah 84111