Form Asd-Neg - Negative Report Of Unclaimed Property For Holding Period Ending:
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2ASD-NEG
Revised 08/27/14
DEPARTMENT OF STATE TREASURER UNCLAIMED PROPERTY PROGRAM
NEGATIVE REPORT OF UNCLAIMED PROPERTY FOR HOLDING PERIOD ENDING:
December 31, 2015 (Life Insurers Only)
June 30, 2015 (All Other
Holders) NEGATIVE REPORTS ARE NOT REQUIRED IN NORTH
CAROLINA PLEASE TYPE OR PRINT IN BLACK INK
Holder Name
Mailing Address
City
State
Zip Code
Telephone #
(
)
FIN#
State of Incorporation
Date of Incorporation
Please indicate the primary business of holder
If you are a successor company, list the names and last known addresses of all previous holders for the last 5 years.
Previous Holder(s)
If you have changed your name, FIN or state of incorporation during the last 5 years, list the prior information below.
Previous Name(s), FIN (s), State of Incorporation and Date(s)
If your report includes property held by subsidiary companies, list the name(s) and FIN(s) of those companies.
Total Number of Employees, including Subs:
Total Number of NC Employees, including Subs:
Is this the initial report of unclaimed property for holder? YES ________ NO ________
Types of Property Reviewed
List Types of Records Reviewed
(See detailed listing on back)
(Bank Reconciliations, Journal Entries, General Ledger, Trial Balances, Logs, etc.)
Wages/Payroll
Accounts Payable/Vendor Checks
Other Checks
(official checks, overpayments, refunds, etc.)
Credit Balances
Gift Certificates
Layaways (deposits and payments)
Securities (stock, dividends, etc.)
Account Balances (checking, savings, etc.)
Insurance (proceeds, benefits, payments, etc.)
Court Deposits
Utilities (deposits, refunds, etc.)
Trust, Investment and Escrow Accounts
Other
Attach additional listings if necessary. The above list includes, but is not limited to, those items that are covered by the North Carolina Escheat and
Abandoned Property Law (G.S. 116B).
Incomplete reports will not be accepted and will be returned for completion.
CERTIFICATION AND VERIFICATION
As the person authorized to bind
, I certify that the above property type(s) and
(Name of Holder)
record(s) have been reviewed for the corresponding reporting period noted above and we are not holding on our records or have
removed from our records property subject to NC G.S. 116B. I have read and completed the information requested on this form.
Name (Please Print)
Title
Date
Signature
NC Department of State Treasurer - Unclaimed Property Program
MAIL ASD-NEG TO:
3200 Atlantic Avenue Raleigh, NC 27604-1668
(919) 814-4200
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