Arizona Form 652 - Unclaimed Property Report - Schedule A
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1Arizona Department of Revenue • Unclaimed Property Section
ARIZONA FORM
652
UNCLAIMED PROPERTY REPORT - SCHEDULE A
HOLDER NAME
Federal Employer Identi cation Number (FEIN) Grand Total Remitted
$
Item no.
Property type
Property description
Last activity date (required)
Cash amount remitted
Interest rate
Fees/Drilling cost
No. of shares remitted
Security/Mutual Fund name
CUSIP no.
O
w
e n
s ’ r
a l
t s
a n
m
e
O
w
e n
s ’ r
fi
t s r
a n
m
/ e
i m
d d
e l
i n i
l a i t
T
e l t i
e R
i t a l
n o
h s
p i
o c
e d
Reference no.
Owner’s Tax ID (SSN or EIN)
Owner’s date of birth
Owner’s e-mail address
O
w
e n
s ’ r
m
i l i a
g n
a
d d
e r
s s
C
, y t i
State, ZIP code
Country
COMPLETE THE FIELDS BELOW IF THERE IS MORE THAN ONE OWNER FOR THIS PROPERTY
Additional owner’s last name
Additional owner’s fi
t s r
a n
m
/ e
i m
d d
e l
i n i
l a i t
T
e l t i
e R
i t a l
n o
h s
p i
o c
e d
Additional owner’s Tax ID (SSN or EIN)
Additional owner’s date of birth Other information available
Additional owner’s last name
Additional owner’s fi
t s r
a n
m
/ e
i m
d d
e l
i n i
l a i t
T
e l t i
e R
i t a l
n o
h s
p i
o c
e d
Additional owner’s Tax ID (SSN or EIN)
Additional owner’s date of birth Other information available
Item no.
Property type
Property description
Last activity date (required)
Cash amount remitted
Interest rate
Fees/Drilling cost
No. of shares remitted
Security/Mutual Fund name
CUSIP no.
O
w
e n
s ’ r
a l
t s
a n
m
e
O
w
e n
s ’ r
fi
t s r
a n
m
/ e
i m
d d
e l
i n i
l a i t
T
e l t i
e R
i t a l
n o
h s
p i
o c
e d
Reference no.
Owner’s Tax ID (SSN or EIN)
Owner’s date of birth
Owner’s e-mail address
Owner’s mailing address
City, State, ZIP code
Country
COMPLETE THE FIELDS BELOW IF THERE IS MORE THAN ONE OWNER FOR THIS PROPERTY
Additional owner’s last name
Additional owner’s fi
t s r
a n
m
/ e
i m
d d
e l
i n i
l a i t
T
e l t i
e R
i t a l
n o
h s
p i
o c
e d
Additional owner’s Tax ID (SSN or EIN)
Additional owner’s date of birth Other information available
Additional owner’s last name
Additional owner’s fi
t s r
a n
m
/ e
i m
d d
e l
i n i
l a i t
T
e l t i
e R
i t a l
n o
h s
p i
o c
e d
Additional owner’s Tax ID (SSN or EIN)
Additional owner’s date of birth Other information available
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ADOR 11017 (9/10)
Previous ADOR 17-2004
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