Form Treas 400a - Unclaimed Property Holder Report Form (Zero Report) - 2012
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TREAS 400A
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By using this report form, I affirm that all records have been researched per KRS Chapter 393) and found no
unclaimed property to report.
CURRENT HOLDER NAME & ADDRESS:
________________________________________
FEIN#: ____-_____________________________
________________________________________
CONTACT_______________________________
________________________________________
TEL.#___________________________________
________________________________________
E-MAIL _________________________________
State of Incorporation ______ Date of Inc. ___________
DO YOU NEED MORE TIME? (SEE PAGE 18)
If holder name has changed show the previous name here: _______________________________________
……………………………………………………………………………………………………………………
Read page 17 before signing affidavit
VERIFICATION
I, ________________________________, swear that I have prepared, or have caused to be prepared, and
have examined this report as to property presumed abandoned under KRS 393 and other applicable state
laws. I am duly authorized to execute this verification by the holder and by law. To the best of my knowledge
and belief, said report is true, correct, and complete.
Signature _______________________________ Title ________________________ Date ___/___/___
KENTUCKY DEPARTMENT OF TREASURY
UNCLAIMED PROPERTY DIVISION
1050 US HWY 127 S SUITE 100
FRANKFORT KY 40601
TOLL-FREE (800) 465-4722
FAX (502)564-4200
e -mail: unclaimed.property@ky.gov
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