Holder Reporting Extension Request Form - Connecticut Office Of The State Treasurer - 2012

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S
C
TATE OF
ONNECTICUT
O
S
T
FFICE OF THE
TATE
REASURER
Unclaimed Property Division
Holder Reporting Extension Request Form
Calendar Year Ending December 31, 2012
We are requesting an extension for:
□
Filing the Report of Unclaimed Property for the year 2012, representing property considered legally abandoned as
of December 31, 2012 and due on or before March 28, 2013. No money is due at this time. Your payment
MUST accompany your holder report.
Note: Extensions will NOT be granted because due diligence was not completed in a timely manner
as per CT statutes or reporting instructions.
Based on the reason(s) below, I am applying for an extension:
Yes
No
Reorganization/Merger
Personnel Changes
New Accounting System
System Problem
Change in Transfer Agent
Other (Please Explain)____________________
I am requesting the following additional time to complete the report:
10 Days
30 Days
45 Days
60 Days
I have verified due diligence has been completed for the property in question. I am duly authorized to execute this request
for an extension on behalf of the holder.
Please complete one form for each entity or company.
Holder Name: _____________________________________________
FEIN#: __________________________
Date of Request: __________________
Name of Signatory:________________________________________ Title:_____________________________
Telephone #:________________ E-mail:____________________________ Fax No:_____________________
Signature: _______________________________________________________________________
__________________________________________________________________________________________________________
TREASURER’S OFFICE USE ONLY
The State of Connecticut’s Unclaimed Property Division will consider the following criteria in evaluating the request.
Yes
No
Explain/Notes
Holder Report #
Company Previously Filed Holder Reports
___________
Never Filed with CT before
Holder Reports Received Timely(3 yrs)
Previous Extension Requests (Consecutive)
Reviewed by: ________________________________ Date: ____________
Approved by: _________________________________ Date: ____________
Maria M. Greenslade, Assistant Deputy Treasurer
Extension Approved
Report will be due on: ___________________
Extension Denied
Explanation: ______________________________
Revised: December 2012

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