Name of Business (Holder)
Alaska Department of Revenue
STATE OF ALASKA
Tax Division
REPORT OF UNCLAIMED PROPERTY
Unclaimed Property Section
AS 34.45
PO Box 110420
Federal E.I.N.
Period Covered
Juneau, AK 99811-0420
Report and remittance due on or before November 1
A
B
C
D
E
F
G
H
I(a)
I(b)
J(a)
J(b)
K
Interest
Amount Due
Owner Last Name, First & Middle Initial (include prefix,
Property
Identifying
Property
Each Owner's SSN or
Last Activity
Ded.
Amount
Add.
Amount and Number of
Bearing
Before
Addition Amount
suffix or title) Street Address, City, State, Zip Code
Code
Number
Type
Federal EIN
Date
Code
Deducted
Code
Shares Remitted
Y/N
Deductions
1
2
3
4
5
6
7
8
9
10
(This form may be reproduced on a spreadsheet)
Total
All items less than $100 may be reported in one
(If this is the last page of report, enter grand total)
aggregate amount - include number of items
Page_____of______
Form 04-720B (Rev. 08/00)
(Please See Instructions)