651State of ArizonaUnclaimed PropertyReporting ManualReport & Instructions2017(602) 716-6031 or (602) 716-6032 (602) 716-7997 AZ UNCLAIMED PROPERTY160 00 West Monr Dear On btimeReveinforrepoChaphelp The abanand becoyou asse If yocontone bookwww AgaiSinc JoshAdm roe Street, Pr Unclaimebehalf of te to file yoenue. We rmative anort, you arpter 3, buing us proUnclaimedndoned asreturn miome an inccomplete ets to the ou should tained in tof the numklet along , thank yerely, ua A. Joycministrator Phoenix AZ 8ed Properthe citizenur Unclaimhave madnd as userre not onlyt you are otect aband Propertyssets alikellions of dcreasingly the first sDepartmehave any his booklembers list with you for hece 5007-2650 ty Holder:s of Arizonmed Propede every er friendly ay complyin performinndoned proy Unit wor. Each yeadollars to iy importanstep by filient of Reve questionset, feel freed within ble forms elping us rS: na, I woulerty Reporeffort to deas possiblng with Arng a valuaoperty. rks hard toar we collets rightfulnt programing this reenue. s about hoee to conta the instruare availareturn proTATE ODld like to trt with theesign this e. By comrizona Revable servico assist hoect thousal owners. m for our geport and ow to comact the Houctions. Elable from perty to itOF ARDepartment thank youe Arizona booklet tompleting yovised Statce to the colders andands of neUnclaimedgrowing premitting mplete the older Comectronic vour websits rightful IZONAof RevenueDww for takingDepartmeo be our annuatutes, Titlecitizenry bd claimantew properd Propertypopulation abandone report forpliance Unversions oite at owner. e Douglas A. DGovernoDavid g the ent of al e 44, by ts of rties y has , and ed rms nit at f this Ducey r ant r T GeRep Co TABeneral OverWhat is UWho muWhat UnReportinWhen toMethod Holder DSample Request porting InstGeneralElectronReport CSchedule SecuritieSecuritieMutual FWorthles Safe DeWhen toHow to RWhen toPackagiDeliverin Negative odes, TablesNAUPA PRelationQuick ReRemit YeUnclaimChecklis FLE Orview Unclaimed Prost report Unclnclaimed Propng Methods ano of DiligenceDue Diligenceing Reimbursetructions Reporting ...ic Reporting ...Cover Page ...e A ...............es Report es RemittanceFunds ............ss or Non-Traneposit Box Reo Report .........Report .........o Remit Safe Dng Contents ...ng Contents ...e Report ......s and ChecProperty Typeship Codes/Peference Guidear Tables ......ed Property Tt ..................orms ............OF Coperty? .........aimed Propeperty should bnd Letter .........ement ........................................ ........................................ ................e .......................................s ferable Secueport ........................................ ..Deposit Box Codes .........ayment Protode ....................................erms ........................................ .............. ...............be reported? ...ents ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ............urities ........................................ ..................ontents ........................................ ........................................ .............ocols ........................................ ........................................ ........................................ ... UnclaimTS ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ .............................. Property Re ...... 1 ....... 1 ...... 1 ...... 2 ...... 2 ....... 2 ..... 2 ..... 3 ..... 4 ..... 5 ..... 6 ...... 7 ..... 8 ..... 9 ....... 9 ....... 9 ....... 10 ..... 10 ....... 11 .... 11 ....... 11 ....... 12 ..... 13-14 ...... 15 .... 16 ...... 17 ....... 18 ..... 19 ...... 20 ov eporting Manuaal Wh Unchas Whethenand The onli Wh Anya truproprepodomare InfoNAU Wh Repcodbusiall u Ghat is Uncclaimed Prope been no ownen efforts by tn responsible d returning the Revised Arizone at must ry person or enust, or who is perty and muort to the Demiciled busine responsible fo Banking private b Business proprieto Other legcorporatormation abouUPA (Nationalhat Unclaportable itemsdes section of iness. In additunclaimed pro Securitieof CACT Safe Depthe leaseA all avathe propGENclaimed erty is a financner contact fothe holder to lfor safeguarde assets to theona . report Unntity in possess indebted to ust report that epartment of esses must alsoor filing repor and financialbankers, savin associations orship, coopegal entities inctions, estates, ut other statel Association oaimed Pros with respect this booklet. tion, Arizona doperty where s representingUS & CO. (Seeposit Box conte must be repailable informaperty. ERAProperty?cial asset oweor a specified locate the owding the fundse owners as thd Property Acnclaimedsion of propeanother perso property to thRevenue anyo report all prots on behalf ol institutions ings and loan awherever locrative, or othecluding state, trusts or any os and their unof Unclaimed operty shive property cHolders must domiciled hold the last knowg underlying se the instructiotents that havorted. Pleaseation, and coAL OV?? ed to an indivi period of timwner fail, the fs, attempting hey come forwct is located in Propertyrty (subject toon on an oblhe state. All hy unclaimed poperty where of their branchncluding stateassociations, cated, such aser association county and cother legal or nclaimed pro Property Admhould be codes and do report all uncders should rewn address is inshares, stock sons for Reportve been unclae complete antact safekee1 VERidual or businee, usually betunds must beto locate theward. n Arizona Revy? o the Act) whigation subjecholders, whetproperty they the owners nhes, divisions o or federally ccredit unions as a corporatio for business pcity governme commercial eperty reportinministrators) wreportedormancy perioclaimed propeport items to n a foreign cosplits, bonds, eting Securities aimed by the n Unclaimed eping represeARVIEWess. Property itween 1 and 3e turned over e owners, pubvised Statutes, hich belongs tct to the Act,ther located y hold that is oname and ador other affiliachartered banand investmeon, joint stock purposes (inclents, political entity. ng requiremeweb site at wwd? ods are locateerty that is owArizona withoountry. etc., must be section for m owner for a pProperty repoentative at (60Arizona UnclaimW is considered 3 years. to the Departlicizing the na Title 44, Chapto another, or, is deemed ain Arizona orowed to Arizoddress is unknates, includingnks, trust comnt companie company, buuding all insur subdivisions, nts can be in the NAUwed to an Arizout an owner registered in Amore informatioperiod of threeort (650C), ind02) 716-6035 tomed Property Re unclaimed wtment of Reveames of appapter 3, and car who is trustea holder of uncr in other stana residents. own. All busig: mpanies, savins. usiness trust, prance compapublic authorccessed UPA property tona resident oname or addArizona s nomon). e years after edicating on theo arrange for eporting Manuawhen there enue which is arent owners an be found ee in case of claimed tes, must Arizona iness entities gs banks, partnership, anies). rities, public ugh the type or ress and minee name expiration of e Schedule delivery of al Re Holdcop For e-m Wh In AMayshalholdthe The Comleng Me All cUnc Ho The theiprop Geporting Mders should repy signed repoassistance wimail us at Repohen to FilArizona, a life iy 1, and the rll file the repoder may also purposes of in Department mpliance Unitgth of time neethod of checks must claimed Prope Do not mthe chec Do not sepayable Do not su Alert theor the cholder Due Act requires tir report, the hperty if all of t The holdthe addr The claim The valueGENMethods eport via CD/Dort coversheeth reporting, cortingUnclaime nsurance comreport shall coort before Nov make a onencome tax purequests extet in writing prioeeded within tPaymentbe made paerty. Your remmake checks pck. end the origin to the Arizonubmit an indiv Unit at Reporheck will be ree Diligencthat prior to oholder shall sethe following aer has an address is inaccurm of the appae of an individERA and ReqDVD or USB flaet. Reports notcontact the HomedProperty@ampany that is over the prior vember 1, ande-time electioursuant to Titleension inquiriesor to either Apthe request. t ayable to Arimittance muspayable to thnal instrument a Unclaimed vidual check frtingUnclaimeeturned unproce one hundred tnd a written napply: dress in the horate. arent owner isdual property AL OVuirementash drive, follot received acolder a holder of pcalendar yead the report son to annualle 43. s for filing a Repril 1 or Octobizona Unclaimst be in he original ow that was issue Property Unitfor each twenty days bnotice to the aolder's records not barred b is at least fifty2 VERts owing the NAUcording to theance Section property that iar. Any other hshall cover they report the eport of Unclaber 1 (whichevmed Property currency. Foner or includeed to the own. perty being if chbefore the holapparent owns for the appaby any other lay dollars. ARVIEWUPA format spe prescribed at (602) 716-6is presumed aholder of prope last twelve property at taimed Properver applies). Unit for the oreign currence the original oner. This officeeported. heck or reportder of properner that statearent owner aaw of this stateArizona UnclaimW pecifications, aformat will be6031 or (602) abandoned shperty that is pmonths beforthe same timrty be submittPlease includtotal amountcy cannot be owner s namee can only det is being mairty that is preses that the holand the recorde. med Property Reand also prove returned for 716-6032. Yohall file its reppresumed abare July 1 of thme it reports itsted to the Holde the entity's t listed on thaccepted. e in the payeeposit checks led under sepsumed abandder is in posseds do not indieporting Manuavide a hard correction. ou can also ort before andoned at year. A s income for der FEIN and he Report of e section of made parate cover doned files ession of the cate that al S Gample D Owner Na123 Main SCity Name Re: (Pro Our recorto the perand/or ph Holder Info If we do nfor refundthe Arizon Sincerely,(CompanStreet AddCity, State P Action to Reissue C Close Ac Other (e _________ _________ _________ GENue Diligeame Street e, State, Zip operty Descds indicate trson listed abhone numbeormation: Co Ad Phnot hear fromd reporting ana Departme ny s Contactdress (Include, Zip Code PLEASE SIGN Printed be taken (PCheck (originccount and xplain) ____________________________________ERAe nce Letteription or Acthat we are bove. The ower listed beloompany Namddress one Numbem the owner and remittingent of Reven Name) de Number) BELOW TO A Owner NamLEASE CHECnal is/is not eSend Check___________________________________ ____AL OVer ccount No.) holding uncwner may claw. me r before (inseg to the Statnue, Unclaim ACKNOWLED me CK ONE) enclosed) k (passbook ____________________________________3 VERclaimed propaim this propert the last de), Arizona lmed PropertyGE OWNERS Update Ais/is not enc____________________________________A RVIEWperty in the aperty by conay that the law requiresy Unit beforeHIP OF THE A Account (palosed) _______________________________________A rizona UnclaimW amount of $ ntacting us acompany c us to submie November ABOVE LISTED Owner Siassbook is/is n____________________________________med Property Re dueat the addrean remove iit this proper 1. D FUNDS ignature not enclosed________________________________ _______eporting Manuae ess items rty to d) __ __ __ al Req After reporReimPleas SecIn thiscontaReporwas reReporare rePropeidentiAggrewas rePropetangibpropeOwnethe owPropeare rerefere SecIn thisseekinHoldethe UnTax Idon theMailinas dereporContayour cdesigForm SecIn thisand in SecIn thisconta Plea1. 2. Only requeinformrespo Gquesting r a report is surt were filed inbursement fose use the curtion 1 section, identifact. rt Year - the yeaeported to the rt Amount theeferencing. erty Type Code fy the propertyegate indicateeported in aggerty Amount - tble properties terty in Name and Adwner as it is shoerty Description equesting, suchence number. tion 2 section, identifng reimbursemeer Name the nnclaimed Propdentification Nue Unclaimed Prng Address theclared on yourt (Arizona Formact Person / Cocompany s desnated on the m650A-C). tion 3 section, carefundemnity agreetion 4 section, a notaact person is reqase Note: All fields in einformation You are reqof cancelle a company eest a holder remation by coonsible for all GENReimbursbmitted, a hon error. In thesorm (Arizona Frrent version, 6fy your companar in which the State of Arizonae total dollar am the property y you are requee if the propertyregate form. the amount of fransmitted to th. ddress - the full own on the repo the descriptio as, the identificfy property for went. name of your certy Report youumber the taxroperty Report e mailing addrr most recent Um 650A-C). ontact Informatisignated State most recent repully read the hoement. arized signaturequired. each section or make payquired to submd check(s), fremployee deeimbursemenmpleting Arizoongoing interERAsement older may chose cases, the horm 670) alon670 revised 09ny and designa requested propa. mount of the reptype code usedsting. y you are requefunds, shares, ohe State, for the name and addort. on of the propecation, check, which the holdeompany as listeu are referencinx id number repyou are referenress of your comnclaimed Propion the namecontact as port filed (Arizonolder declaratioe of the designa of the form myment. mit documentaont, and bacesignated as tnt. An officer ona Form 285raction with thAL OVoose to repay holder may seng with the req9/09. All otheated perty port you d to esting or e dress of erty you or other er is ed on ng. ported ncing. mpany erty e of na ons ated must be complation to suppok, evidence ohe Unclaimed of your comp5UP and Arizohe Arizona Un4 VER the owner dieek reimbursequired documer forms are obleted before tort your claimof account read Property copany may chana Form 650Anclaimed PropARVIEWrectly or mayement by submmentation subbsolete and wthe State of Arm for reimburseactivation, orontact on the lange the desA(Sections 1 aperty SectionArizona UnclaimW y determine thmitting the Hobstantiating thwill not be acc rizona will proement, whichr a sufficient lelast report (Arsignated contand 2). The de. med Property Rehat items withiolder Request he repaymentcepted. ocess your req may consist oetter of explanrizona Form 6tact person/ cesignated coeporting Manuain the for t or error. quest for of copy nation. 50A-C) may contact ontact will be al We aIf you Plea R Generaask that you au have any quase Note There 65 65 65 It is imregiste It is imrespo Includ So D Po Thec ReporREPl Reportindhere to the uestions, plea is a different 50A - Cash on50B - Securitie50C - Safe Demportant that yer any stock/mmportant that ynsible for chode all known oocial security ates of Birth olicy, accoune more infothey arelaimants tort Cover Page 650ORTng procedures ase call (602) 7report cover nly es and Cash eposit Box Conyou familiarizemutual fund. you review thoosing the codowner identifieor Tax Id numnt or check nuormation te to contao your esc 0 A TINGand forms inclu716-6031 or (60page for eacntents only e yourself withe payment pde that correcers for each pmbers umbers the State rect you eaccheatmentReport Co5 G INSuded in this b02) 716-6032. ch type of proh the instructiorotocol for eactly reflects thproperty eceives wich time a ct specialistover Page 650 B ASTRUbooklet. perty you areons for reportiach relationshhe named perith your reclaim is filet for additioArizona UnclaimUCTIe reporting: ng securities bhip type that yrson s relationport the leed or to reonal informReport Covemed Property ReIONSbefore you trayou report. Yonship to the press likely efer mation. er Page 650 C eporting ManuaS ansfer or re-ou are roperty. al Ele We It is Or yo SendReporemit Passwline oAppr Rectronic R recommend required that Use a CD, Clearly labdisk and t When repseparate f Type all reou may send d passwords aortingUnclaimettance. CD ROMrequire p CD ROMshould bwords for non-of the e-mail mroved reportinREPReportingthat you upda data be sent DVD or USB flbel the outsidhe format useorting multiplefile name. ecords in UPPE to us via UPExnd/or instructedProperty@aMS and USB flapassword protMS and USB flae sent under -encrypted filmust identify tng software is Arizondownpackwwwinstru(303) ArizORTg ate your softwt according tolash drive. e of the disk wed ( , Wage companies ER CASE style. xpress. Magnetic tions for or psh drives in NAtection. sh drives in NAprotected mees need to behe report(s) p available, frena does not pnload this freekage to Fction to down 413-9450. zona will no TINGware yearly aso these specifwith the holdeers, HRS, or NA on one CD, D tape or cartriving data whiprovide a conAUPA format tAUPA format teans. e e-mailed proprotected by tee of charge aprovide techne software andt unclaimed pFrom the mainnload. For queo longer a6 G INSs the standardfications: er name, holdAUPA). DVD or USB flaidge media isch is passworntact person athat contain tthat contain tomptly to repthe passwordat: nical support od User s manuproperty on an page, click oestions or addaccept RepASTRUd reporting forder address, nash drive assigs not acceptard protected oand telephonethe HDE file the HRS file portingunclaim. of HRS Pro, houal from Xeroxa CD ROM or Uon the Free Hditional informports in ExcArizona UnclaimUCTIrmat does chaames of eachgn each compable. or in special ee number with extension are extension aremedproperty@owever, holdex Reporting SyUSB drive in NAolder Softwarmation, pleasecel Formatmed Property ReIONSange. h file containepany a encryption sofh your report ae encrypted ae not Ters may continystem (HRS) soAUPA format re icon and foe contact Xerot eporting ManuaS ed on the ftware to and and do not ed and he subject nue to oftware at ollow the ox Wagers at al Re This f SecIn thanddesrespinteUnccorrreimaddAn ochaperscomArizo SecIn thcomUnchavanswcomyouyouprac SecIn ththe SecIn thholdagre SecIn themprepo Report Covform must bection 1 his section, ided designated ignated contponsible for aleraction with tclaimed Properespondencembursements wdress reportedofficer of youange the desigson/contact impleting Arizoona Form 650ction 2 his section, idempany s custoclaimed Propeve questions thwered by an mpany who is r escheatmenr internal procctices. ction 3 his section, sum property you ction 4 his section, cader declaratioeement. ction 5 his section, theployee authoort is requiredREPver Page e submitted entify your cocontact. The tact will be ll ongoing the Arizona erty Section. and holder will be sent tod at this time. r company mgnated containformation bona Form 285U0A(Sections 1 entify your omer contacterty clients wilhat can only bemployee of not only famint policy, but cedures and mmarize and are reportingarefully read thons and indeme signature ofrized to execu. ORT in hard copy mpany Future the may act by UP and and 2). . l often be your iliar with also classify g. he mnity f the ute the TINGy. 7 G INSASTRUArizona UnclaimUCTImed Property ReIONSeporting ManuaS al SchThe DreporIteEnumeAcProvidpropeChIndicarepor te PrIndicafor thepropeCaIndica IntIf the a LaIndicalast owpropedate oownerOwPleasenamesincludiif it is dOwIndicaentity FeIf you abox, pmay bCUIf you anumbeCUSIP, It is imand i Rhedule A Department rerting softwareem no: erate each item yccount Number: e an account nurty being reportedheck no: te a check numbed. roperty type: (Mate the NAUPA proe category that berty you are remittash amount remittte the dollar amoterest rate: account is currentst activity date: te either the checwner-directed accrty became payaof last contact ber, whichever applwner s name and e furnish the entires should be listed ing zip code. If thdetermined that mwner s tax ID: te the owner s sos tax identificatioes/Drilling Costs: are reporting the lease list all fees tbe released to theUSIP no: are reporting a seer. If you are repo bond number, amperative thaidentification REP ecommends te, please contyou are for the indivd. ber for the properndatory field) operty code (see est describes whaing. ted: ount due owner(stly earning interesck issue date, thecount activity, theable or distributabetween the compies. mailing address:e name, if known, exactly as adopthe complete addmail is no longer docial security numn number. contents of a safthat are due befoe reported , indicate torting a bond, indnd any coupon nat ALL pertinen of the correcORThat you submtact our Holde. vidual rty being enclosed list) at type of ). st, list the rate. e date of the e date the ble, or the pany and the DO NOT LIST JOIN including any titlted. If the name dress is not availabdeliverable to the ber or the fe deposit ore the box . he CUSIP dicate the numbers. nt property fiect owner. TINGmit your report er Complianc NT OWNERS ON THe, such as Jr., Sr., is unknown or no ble, indicate the p owner at the addOwner s dateIndicate the own Number of shIndicate the acturemitted for eacOwner s dateIndicate the ownelds described8 G INS in electronic e Specialists aHE SAME LINE. or III. Corporate longer available,portion of the adddress. e of birth: ner s date of birthhares remitted: ual number of shah individual ownee of death: ner s date of dead above are tASTRU format. For aat (602)716-60 titles, names of tr, indicate that in tdress that is knowh (if known). ares being er. th (if known). horoughly co Arizona UnclaimUCTIassistance in d031 or (602)71 rusts, estates, partthis field. Please fwn. The last knownRelationshipPlease refer to tprotocols on thSecurity/MuIndicate the namutual fund if yJoint OwneEnter additionafollow proceduompleted. Thismed Property ReIONSdownloading 6-6032. tnerships, associafurnish a completn address should p code: (Mandatothe relationship ce following pageutual Fund name:ame of the securityou are reporting er s information al owner s informares on step 8. s will aid in theeporting ManuaS or using free tions, and trade te address be reported eveory field) codes/ payment e. : ty, bond, or them. ation, please e location al n Se Any sremadistrib Se Com Stoc HoldPart Forwto thIf pr InclProp Diviandwho Mu Plea86-6A cofundIt is escIf yo Wo Do nandIf yo Rcurities Rstock or otherains unclaimedbution. curities Rmplete the Reck must be reders who partticipant #901;ward, via fax the transfer. Inrior notificatioude a copy operty Unit of thdend Reinvesd register the wole shares andutual Fun ase transfer th6004791. opy of the fund reported. Mincumbent upheatment proou need help,orthless onot report word remit the shaou are reportinREPReport r equity intered by the owneRemittanceport of Abangistered in Articipate in DTC; Account #82to Vilka Markoclude in this nn is not receivof the DTC conhe Arizona Destment Plans wwhole shares id the amount ds he abandonends statementMutual fund stapon holders toocess, they int, call (602) 716or Non-Trarthless or non-ares at that timng securities fORTst in a busineser for more thce doned Securizona s nominC (Depository 22432; Agent ovich (617) 72notification theved by Ms. Manfirmation aloepartment of will not be accinto our nomin of cash in lieued shares to aSend all staArizona DepAttn: Arizon1600 W. MoPhoenix, AZ t showing theatements muso contact thetend to transfe6-6031 or (602ansferab-transferable me. You will nrom a safe deTINGss association han three yeaities 650B. All nee name of C Trust CompaBank 26500; T22-9660, notifice following: Issarkovich, the ong with the URevenue. cepted in boonee name. Thu of fractionan account regatements to: partment of Rna Unclaimed onroe Street DZ 85007 transfer of fust be sent to the individual muer shares into 2) 716-6032. ble Securisecurities to onot be penalizeposit box, ple9 G INS or financial ors after the da information mCACTUS & COny) must transTax ID #75-312cation of secusue Name; CU transfer will bUnclaimed Prook entry form. he report musl shares that agistered to theRevenue Uncla Property AdmDivision Code nds to the Dehe address listutual fund co an account fities our office. If thzed for late reease use the IASTRUorganization isate of the momust be typedO. sfer re-register21666. urities being trUSIP #, numbee rejected anoperty Report Convert eacst indicate, foare due. e State of Arizaimed Properministrator 10 epartment muted above. ompanies to infor the State ohese do becoeporting in theInstructions foArizona UnclaimUCTIs presumed aost recent dividd or printed clred securities ransferred at ler of shares and returned to you submit toch owners acr each individzona, Unclaimrty Unit ust be includenform them thof Arizona. ome transferaese situations. or Reporting Samed Property ReIONSbandoned if tdend, stock splearly in ink. directly to: DTleast 24 to 48 nd depositoryo the holder. o the Unclaimcount to whodual owner, thmed Property ed with the rephat as part of able or gain va afe Deposit Boeporting ManuaS the property plit or other TC hours prior y number. med ole shares, he number of Unit, Tax ID port for each the annual alue, report ox Contents. al Safe Tangowne Wh Safe box c How The fo Plea Re Deposiible property er for more thaen to Rep deposit box ccontents onlyw to Repoollowing infor Repo Electro A legib Safe Depoase note: DO NOT re Report ea Keep a co Regardingowner. Ple You shouldsafe keepover to a Report feeRepoREPit Box Rep that is held inan three yearport contents must. Submit the oort mation shouldrt Cover Sheeonic Report (Oble and readaosit Box Repeport empty bach box only Oopy of your reg UNKNOWN oease note thad contact youping receptaclaw enforcemes or drilling cort Cover Page 65ORTport n a safe deposrs after the ext be reported owner namesd be includedet 650 C Owners informable copy of ports needs boxes. ONCE. eport and inveowners: it is imat the unknowur local law ecle. Make a noment agency. osts owed on 50 A TINGsit box is presuxpiration of the annually befos and addressd with each remation, TAX IDeach invento to be file seentories for yomportant to lowns are still repnforcement aote on your in your electronElec10 G INSumed abandoe lease or renore Novembees electronicaeport: , Box numberory sheet for eeparately frour records. ok at the conportable if theagency for coventory sheetnic report. ctronic Report ASTRUoned if the prtal period on er 1st. Use formally using the r, past due reneach box reporom your cntents, as theyre is no identionfiscation of ts explaining tArizona UnclaimUCTIroperty remai the box. m Arizona 650 NAUPA appront and/or drilliorted ash and sey may help yofication made all controlledthat the itemsSample of med Property ReIONSns unclaimed0C to report saoved format. ing fees, etc) ecurities repou identify thee. substances fos were found, Inventory Sheet eporting ManuaS d by the afe deposit ports. e actual ound in any but turned al Wh DO NSupe Pac Del The DdelivSupe If youyou sDepaDepa SendArizoUnclaVault1600 Phoe Ren to RemNOT send safeervisor will conckaging C The conteto preventsecurity tathe sealedshaped otorn. Each conmore than Prepare 2 copy to thowner nam Place envcontainer livering CDepartment reery if indemniervisor who cau choose to sesubmitted in Nartment will veartment shall nd contents to: na Departmeaimed Propert Supervisor W Monroe Dienix, AZ 85007 REPOmit Safe D deposit box tact you withContentsents of each sat access to thape and heatd container, bbjects as itemtainer of contn one envelop copies of thehe outside of eme, box numvelopes in a shr Box __ of __ Contents ecommends tfied by the hoan be reachedend by courieNovember, incerify that eachnotify you of aent of Revenurty Unit vision Code 1 ORTDeposit Bcontents with a report cons afe deposit boe contents. Tht sealed packbag, or enveloms are tossed atents should bpe for each oe inventory foreach containber and deschipping conta(Box 1 of 3 Owthat contents older. These ad at (602) 716er, use an insurcluding Schedh set of conteany discrepane 0 TINGBox Cont your report. Afirmation numox must be plahe Departmenkages. The coope holding tharound duringbe clearly labeowner, please r each ownerner of contentcription of eacainer, alphabewners A-F, Box are deliveredarrangements-6035. red carrier in odule A, must aents received ncies with the11 INStents After you remmber and remaced into a cnt will acceptontents must bhe items. Be eg shipping andeled with the indicate 1 of . Place the orts. Each invench item of proetically by owx 2 of 3 Owned in person bys must be madorder to safegaccompany th at delivery co report. ASTRUit your report,ittance instruccontainer, bagt most forms obe delivered inespecially cared the envelopowners name 2, 2 of 2, inside wntory sheet shooperty. wner name. Laers G-R, Box 3 oy an employede with the Aguard and trahe contents oorresponds toArizona UnclaimUCTI, the Unclaimections. g, or envelopeof tamper pron a container eful with fragipes they are se and the box. with the conteould include yabel the outsidof 3 Owners Se of the bankArizona Unclaimack packagesof the boxes y a name on tmed Property ReIONSed Property Ve that is propeof seals includ that is separaile, heavy, or isent in can bex number. If yoents and attacyour compande of the ship-Z). k, but will accmed Propertys. A copy of thyou are remitthe Schedule Aeporting ManuaS Vault erly sealed ding ate from irregular e ripped or ou need ch the y name, ping ept courier y Vault he report ing. The A. The al Neg The Nperio DO N SecIn threpoconrespwithSecholdaddof ydesiinfo285Uand SecIn thdec The to e Rgative ReNegative Repood. Should yoNOT file Negatction 1 his section, ideorting period atact. The desponsible for alh the Arizona tion. Future cder reimbursemdress reportedour companyignated contrmation by coUP and Arizond 2). ction 2 his section, caclarations and signature of texecute the reREPeport ort of Unclaimu have any qtive reports onentify your comand designatignated contl ongoing inteUnclaimed Prcorrespondenments will be d at this time. y may changeact person/completing Arizna Form 650Aarefully read thd indemnity agthe employeeeport is requireORTmed Property aquestions, conn CD, DVD or Umpany, the ted tact will be eraction roperty ce and sent to the An officer e the ontact zona Form (Sections 1 he holder greement. e authorized ed. TINGapplies to enttact the RepoUSB flash drive 12 G INStities that havorting Speciale. ASTRUe no unclaimlists at (602) 71NegativArizona UnclaimUCTIed property t16-6031 or (60ve Report Form 65med Property ReIONSto report for th02) 716-6032. 50D eporting ManuaS he required al NA Dorm ACACACACCK0CK0CK0CK0CK0CK0CK0CK0CK0CT0CT 0CT0CT0CT0IN0IN02IN0IN04IN0IN0MI0MI0MI0M I0MI0 CUPA Propmancy Perio01 (3) 02 (3) 03 (3) 04 (3) 01 (3) 02 (3) 03 (3) 04 (3) 05 (3) 06 (3) 07 (3) 08 (15) 09 (3) 01 (2) 02 (2) 03 (2) 04 (2) 05 (2) 1 (3) 2 (3) 3 (1) 4 (3) 5 (3) 6 (3) 01 (3) 02 (3) 03 (3) 04 (3) 05 (3) CODEperty Typds (in years) CHECKING ASAVINGS ACCERTIFICATESCHRISTMAS CCASHIERS CCERTIFIED CREGISTERED TREASURERS DRAFTS WARRANTS MONEY ORDTRAVELERS CFOREIGN EXESCROW FUNCONDEMNAMISSING HEIRSUSPENSE ACOTHER COURINDIVIDUAL PPAYMENTS GROUP POLIPROCEEDS DMATURED POPREMIUM REFUNIDENTIFIEDNET REVENUEROYALTIES/POVERRIDINGPRODUCTIONWO RKING INES, Te Codes are listed in ACCOUNTS CCOUNTS S OF DEPOSIT CLUB ACCOUHECKS HECKS CHECKS CHECKS DERS CHECKS CHANGES NDS ATION AWARDRS FUNDS CCOUNTS RT DEPOSITS POLICY BENEFCY BENEFITS DUE BENEFICIAOLICY PROCEEFUNDS D REMITTANCEE INTERESTS ROCEEDS G ROYALTIES N PAYMENTS NTERESTS TABL parenthesisACCOUNTNTS UNCASCOURDS INSFITS OR CLAIMARIES EDS ES MINERA13 LES A. T BALANCES AC05 (AC06 (AC07 (AC08 (SHED CHECKCK10 (CK11 (CK12 (CK13 (CK14 (CK15 (CK16 (CK51 (RT DEPOSITS CT06 (CT07 (CT08 (CT09 ( SURANCE M IN07 (IN08 (IN09 (IN10 (IN12 ( AL PROCEEDMI06 (MI07 (MI08 (MI09 ( AAND C DUE (3) MONIE(3) SECUR(3) UNIDEN(3) SUSPENKS (3) EXPENS(3) PENSIO(3) CREDIT(3) VENDO(3) CHECK(3) OTHER (3) CD INT(3) ELECTRINSTRU(2) VICTIM(3) CHILD (2) COURT(1) CLASS (3) OTHER TERMS (3) AGENT(3) DRAFTS(3) DEMUT(1) POLICYDEATH DS (3) BONUS(3) DELAY (3) SHUT-IN(3) MINIM Arizona UnclaimCHECES LEFT ON DEITY DEPOSITS NTIFIED DEPOSNSE ACCOUNSE CHECKS ON CHECKS T CHECKS OR OR CHECKS KS WRITTEN OF OUTSTANDINTEREST CHECKRONIC TRANSFMENT MS RESTITUTION SUPPORT PAYT FEES ACTION SETTL AMOUNTS DU T CREDIT BALAS UNPRESENTETUALIZATION Y/ANNUITY PA SES RENTALS N ROYALTIES UM ROYALTIESmed Property ReCKLIPOSIT SITS TS MEMOS FF TO INCOMEG OFFICIAL CKS FER WITHOUT AN YMENTS LEMENT PROCUE UNDER POANCES ED AYABLE ON PRS eporting ManuaST E CHECKS A WRITTEN CEEDS LICY ROOF OF al MS0MS0MS0MS0MS0MS0MS0MS0SC0SC0SC0SC0SC0S C0SC0SC0SC0SC1SD0HS0HS0IR01IR02IR03IR05T R0TR0TR0TS0UT0UT0 C01 (1) 02 (1) 03 (3) 04 (3) 05 (3) 06 (3) 07 (3) 08 (3) 01 (3) 02 (3) 03 (3) 04 (3) 05 (3) 06 (3) 07 (3) 08 (3) 09 (3) 10 (3) 01 (3) 01 (2) 02 (2) 1 (2) 2 (2) 3 (2) 5 (2) 1 (3) 2 (3) 3 (3) 1 (2) 01 (2) 02 (3) CODEWAGES COMMISSIONWORKERS COGOODS OR SCUSTOMER OUNIDENTIFIEDUNREFUNDEDACCOUNTS PDIVIDENDS INTEREST (BOPRINCIPAL PAEQUITY PAYMPROFITS FUNDS PAID FUNDS FOR SSHARES OF STCASH FOR FRUNEXCHANGSAFE DEPOSIHEALTH SAVIHEALTH SAVIINVESTMENT TRADITIONALTRADITIONALTRADITIONALROTH IRA CAPAYING AGEUNDELIVEREDFUNDS HELD TRUSTEE SALEGOVERNMENMEMBERSHIPES, TMISCNS OMP. BENEFITSSERVICES PAYOVERPAYMEND REMITTANCED OVERCHARGPAYABLE ND COUPONSAYMENTS MENTS TO PURCHASESTOCKS TOCK RACTIONAL SHGED STOCK T BOX CONTETNGS ACCOUNNGS ACCOUNL IRA CASH L IRA MUTUAL L IRA SECURITIASH TRUST, INENT ACCOUNTD/UNCASHED IN FIDUCIARYES PROCEEDS NT UTILITIES DEP FEES TABLCELLANEOUSS YMENT NTS ES GES SES) E SHARES HARES TANGIBENTS TAX DEFFERRNT NT FUNDS ES NVESTMENT ATS DIVIDENDS Y CAPACITY TRUS UEPOSITS 14 LES A INTANGIBLEMS09 (MS10 (MS11 (MS13 (MS15 (MS16 (MS17 (MS18 (CURITIES SC11 (SC13 (SC14 (SC15 (SC16 (SC17 (SC18 (SC19 (SC20 ( BLE PROPERTYSD04 (ED SAVINGSIR06 (IR07 (CS01 (CS02 (CS03 ( AND ESCROWTR04 (TR05 ( STEE SALES UTILITIES UT03 (UT04 (AAND CE PROPERTY (3) A/R CR(3) DISCO(3) REFUND(3) UNCLA(1) DISSOL(3) MISC O(3) MISC IN(3) SUSPEN(3) OTHER OF OW(3) STOCK(3) DEBEN(3) GOVER(3) MUTUA(3) WARRA(3) BONDS(3) DIVIDE(3) CREDIT Y (90 days) STS PLANS (2) ROTH I(2) ROTH I(2) ESA CA(2) ESA MU(2) ESA STO W ACCOUNT(3) ESCRO(3) TRUST V (3) REFUND(3) CAPITAArizona UnclaimCHECREDIT BALANCOUNTS DUE DS DUE AIMED LOAN CLUTION OR LIQOUTSTANDINGNTANGIBLE PRNSE LIABILITIES CERTIFICATESWNERSHIP K CONVERTEDTURES RNMENT SECUAL FUNDS ANTS (RIGHTS)S END REINVESTMT BALANCES TORAGE FACILRA MUTUAL FURA STOCKS ASH UTUAL FUNDS OCKS TS OW ACCOUNTVOUCHERS DS OR REBATEAL CREDIT DISTmed Property ReCKLICES COLLATERAL QUIDATION PRG CHECKS ROPERTY S URITIES AND BO) MENT SHARES LITY SALE PROUNDS TS ES TRIBUTIONS eporting ManuaST ROPERTY ONDS OCEEDS al Rela PleasIndivimust CodAG AD AN BF CF CP IN JS OR PA RE SO TC TE UT Cationshipse carefully reidual names r indicate the de Agent for AdministrAnd (UnspBeneficiarCustodianCommuniInsured Joint TenaEither ParPayee Remitter Sole OwneTenants inTrustee Uniform TCODEp Codes/eview the relareported withorelationship foDefinitionOwner ator of Estate ecified Joint Relatry n ty Property ants with Rights rty is Owner er n Common Transfer/Gift to MES, T/Paymenttionship codeout a relationor each. All aRn ionship) of Survivorship Minor TABLt Protocoes to ensure thship code willaccepted relaRelationThe individuaindividual(s) they continueissued in theclaiming on t(Examples: PoA person or eestate of a peRepresentatiNamed indivito claim sepaEach individunon demutuaThe individuanamed as owowner(s) mayProperty or egift, devise, oequal share oIndividuals nawill be paid. property will Each individuequal share oto the surviviFirst named iEach individuEach individuThe sole namEach individuproperty unleproperty will will, probate The individuaThe Trustee wauthority to athe Trust. The minor orminor if they15 LES Aols hat your compl be coded asationship codenship Coal or entity namenamed as ownee to have autho name of the owheir own behalfower of Attorneentity appointederson who has dve). Payment widuals must claimarately. If paid iual named as a balization propertal or entity namewner(s). Paymeny also receive paearnings receiveor descent. Eachof the as the insuIf the beneficiarbe paid to the eual named as a jof the owner(s). ndividual/entityual named as a pual named as a rmed owner will bual named as a tess other percenbe treated as thorder or Arizonaal or entity namewill be required act on behalf of r guardian of they have reached tAAND Cpany is indicas payees. If thes are listed bodes Paymented as agent mayer(s). The Agentrity to act on bewner(s). Any naf. ey, Guardian, Attd by a court of codied (Examples: will be issued tom together or shindividually eachbeneficiary will bties only the inded as custodian nt will be issued ayment by claimd by a husband h spouse should. Upon the deatured will not be ry is deceased aestate of the indjoint tenant wit. Deceased indivy who claims propayee will be paiemitter will be pbe paid the proptenant in commntages are specihe estate of the a intestate statued as Trustee mto provide verifthe named owne minor may claithe age of majoArizona UnclaimCHECating the correhere is more thbelow. t Protocol y claim property t will be requiredehalf of the namamed owner(s) mtorney for, Consompetent jurisdExecutor, Execuo the Estate. how good causeh owner will recebe paid an equaldividual named acan claim on bein the name of ming on their owand wife duringd be listed as an th of one, the prpaid. The indivnd no successordividual named ath rights of survividual s portion operty will be paid an equal sharpaid an equal sherty. mon will be paid ified. Deceasedindividual and wutes. ay claim propertfication that theyner. Payment wm. Payment writy or otherwismed Property ReCKLIect payment phan one owne on behalf of thed to provide vered owner. Paymmay also receiveservator) iction to adminitrix, and Person, such as divorceeive an equal sh share of the proas beneficiary wehalf of the indivthe owner(s). An behalf. g marriage, otheowner and will roperty goes to tvidual named as r beneficiary exisas the insured. ivorship will be of the property aid the entire pre of the properthare of the propean equal share d individual s porwill pass as instrty on behalf of ty continue to hawill be issued in will be issued to tse to the Custodeporting ManuaST protocol. er, you e ification that ment will be payment by ister the nal e or death, hare. operty. For ill be paid. vidual(s) Any named r than by be paid an the survivor. beneficiary sts the paid an will be paid operty. ty. erty. of the rtion of the ucted by the Trust. ave the the name of the reported dian. al Qui Cick ReferMake Mail RepoStock RegDividend RemitRepoAReSign CODErence GuChecks Payaort w/Remittangistration & De(See pMutual (See P Reinvestment(See PSafe Deposit (See Pat & Report Dueorting RequireAggregate RepDue Dilig(See peciprocal RepNegative Rnature RequireES, Tuide able To: Arizo nce To: Arizo1600Pho elivery: page 9) NomTax VilkaXero Funds: Page 9) ArizoUnc t Plans: Page 9) Will Boxes: age 10) ConArizoUnc1600Pho e Date: PriorFor p PriorFor pements: A NAprop If yoelec Onlysoftw(Schporting Dueava gence: page 2) Mus porting: Holdthe state Reports Are ements Hold TABLona Unclaimeona Unclaime0 W Monroe Denix, AZ 85007minee name: CID #75-312166a Markovich (ox Business Seona Departmlaimed PropeNOT be accentact Vault Suona Departmlaimed Prope0 W Monroe Denix, AZ 85007r to Novembeproperty presur to May 1st property presuAUPA formattperties. Free soou utilize any Uctronic file crey 10 or fewer pware to produhedule A). e Diligence is nilable owner dt be mailed 1ders should reproperty for oes laws and p NOT requiredder report mus16 LES Aed Property Uned Property UnDivision Code 7 Cactus & Co 66 617) 722-9660rvices LLC ent of Revenuerty Unit epted in book pervisor (602)ent of Revenuerty Unit Division Code 7 er 1st all busiumed aband for all life insuumed abandted file on CDoftware availaUnclaimed Proeated using elproperties mauce your reponot required odetail includin20 days prior port propertyother states is procedures. d in the State ost be signed bAAND Cnit nit 10 0 ue k entry form 716-6035 ue 10 nesses other tdoned as of Juurance entitiesdoned as of DD ROM or USB fable (UPExchoperty Reportlectronic meday be submitteort, then you mon properties ng those item to report suby to the state osubmitted, it mof Arizona. by an authorizArizona UnclaimCHECthan life insuraune 30 s only ecember 31stflash drive forange or HRS Pting software, dia (CD/USB/Ued manually. must use formunder $50. Pls under $50. mission. of the owner must be in cozed employeemed Property ReCKLIance entities t r reports with 1Pro). you MUST fileUPExpress). If you do not ms 650A or 650lease provides last known aompliance wite of the entityeporting ManuaST 11 or more e the use B and 652 e all address. If h those y. al Rem NON LIFE Cmit Year TN-LIFE INSU One year aItems that wduring the 7/01/2014 t7/01/2015 t7/01/2016 t7/01/2017 t Three yearItems that wduring the 7/01/2012 t7/01/2013 t7/01/2014 t7/01/2015 t INSURANC One year aItems that wduring the 01/01/201501/01/201601/01/201701/01/2018 Three yearItems that wduring the 01/01/201301/01/201401/01/201501/01/2016 CODETables URANCE ENabandonmewere issued o period: through 6/30/through 6/30/through 6/30/through 6/30/r abandonmwere issued o period: through 6/30/through 6/30/through 6/30/through 6/30/CE ENTITIESabandonmewere issued o period: 5 through 12/36 through 12/37 through 12/38 through 12/3r abandonmwere issued o period: 3 through 12/34 through 12/35 through 12/36 through 12/3ES, TNTITIES ent period or had a last a/2015 /2016 /2017 /2018 ent period or had a last a/2013 /2014 /2015 /2016 S nt period or had a last a31/2015 31/2016 31/2017 31/2018 ent period or had a last a31/2013 31/2014 31/2015 31/2016 TABLactivity date activity date activity date activity date 17 LES AMust beNovemNovemNovemNovemMust beNovemNovemNovemNovemMust beMay 1, May 1, May 1, May 1, Must beMay 1, May 1, May 1, May 1, AAND Ce included onber 1, 2016 ber 1, 2017 ber 1, 2018 ber 1, 2019 e included onber 1, 2016 ber 1, 2017 ber 1, 2018 ber 1, 2019 e included on2017 2018 2019 2020 e included on2017 2018 2019 2020 Arizona UnclaimCHECn the report pon the report pon the report pon the report pomed Property ReCKLIostmarked beostmarked beostmarked beostmarked beeporting ManuaST efore: efore: efore: efore: al Unc AbaTangpropspecestatAbaThe pconsiActiActiomakichecowneAggThe adue dto repaggravailCusAn indelivthe stDateThe dpropDueThe sabanownethe SHoldAny bentityanotpropIndeAn aloss. Cclaimed andoned oible (safe deperty that is unified period ote. andonmenperiod of inacidered abandivity on taken on png a deposit ck, or a documer to the Holdgregate Amamount belowdiligence andporting funds regate amounable owner dstodian ndividual or enered to the rigtate the custe of Last Adate of the owerty or the owe Diligencetatutorily requndoned propeer of propertytate. der business, indivy in possessionher party untierty programemnificatiogreement thaCODEProperty or Unclaimposit box contclaimed by itof time. This dont Period ctivity after whdoned. roperty by theor a withdrawmented commer. mount w which the Hd attempt to c as unclaimednt in Arizona isdetail. ntity that holdghtful owner. todian of abActivity wner s last actwner s contace uired degree erty must use before the pvidual, governn or control ofl transfer to a . on at protects theES, T Terms ed Propertents) or intans rightful owneoes not includhich property e owner incluwal, negotiatinmunication byolder need nocontact the od property. Ths $50. Please ps property unMost states laandoned protivity related tct with the Holof effort a Hoto find the rigroperty is remnment body, of property bel State unclaime Holder or StaTABLty ngible er after a e real is ding ng a y the ot perform owner prior e provide all til it is aws make operty. to the der. lder of ghtful mitted to or other onging to med ate from 18 LES A OfficiaA checkorganizaincludingtraveler OwnerA personabando RecorInformatthat is stois retrieva ReportA list of opropertiebasis. TangibPhysical boxes. UnderlShares oassociaticertificatshareholdividendcorp orat AAND Cal Check k or written insation, or busing, but not limis checks, casr n having a legned propertyrd tion that is inscored in any elable in a perct owners and thes that is filed ble Persona property, suclying Sharef stock that hion or a finantes for the shalders, who havd checks or cotion. Arizona UnclaimCHECtrument for wess associatioted to, drafts,shier s checksgal or equitaby. cribed on a talectronic or oceivable formhe value of th with the Depal Propertych as objects kes ave been issucial institutionares are in theve failed to eorrespond witmed Property ReCKLIwhich a bank, on is directly lia, money orde, and expenseble claim to thangible mediuther medium m. eir unclaimedpartment on ay kept in safe dued by a businn. The original e possession oeither cash theth the issuing eporting ManuaST financial able, rs, e checks. he um or and that d an annual eposit ness of the e al Che Cecklist Have yreport f Have y Have yIf reporting Have y Have th Have y Have y If reporting Have thDepart Have y If reporting Have y Have yrepots? Have yreporteCODEyou enteredform? you encloseyou encloseg securities:you followedhe securitieyou compleyou encloseg mutual funhe mutual ftment of Reyou encloseg safe depoyou followedyou enclose? you encloseed? ES, Td the requireed your cheed your Sch: d the Instrues been re-reted the aped notificatinds: funds beenevenue, Unced the mutuosit boxes: d the Instrued your Safeed a legibleTABLed holder aeck made pedule A? Ictions for Seregistered inppropriate sion of any D transferredclaimed Proual fund coctions for Sae Deposit Be and reada19 LES Aand remittapayable to:s all of the ecurities Ren the State security infoDTC share td to an accoperty Unit,nfirmation safe Deposiox Report sable copy oAAND Cance inform: Arizona Unavailable oemittance? of Arizonaormation ontransfer withcount in the, FEIN 86-60statementst Remittancseparately of each invArizona UnclaimCHECmation on thnclaimed Powner inform s nomineen Schedule h your repoe name of t004791? s? ce? (See pafrom your cventory shemed Property ReCKLIhe front pagProperty Unimation incle name? A? ort submissiothe Arizonaage 10) cash and seet for eacheporting ManuaST ge of your it? uded? on? ecurities h box al Arizona Department of Revenue Unclaimed Property SectionREPORT OF ABANDONED PROPERTYADOR 10755 (3/14)DO NOT STAPLE REPORT/CHECKSI hereby certify that I have the authority to execute this report of Unclaimed Property on behalf of the above named holder. I declare under penalty of perjury that the foregoing information, the information set forth in the schedules, and all documentation I have or will provide is true and complete. Print Name Signature DateMAIL TO: Arizona Unclaimed Property Section 1600 West Monroe Street, Division Code 10 Phoenix, AZ 85007If you are remitting securities, please use Arizona Form 650BIf you are remitting safe deposit box contents, please use Arizona Form 650C12345If your report contains more than 10 items you MUST submit an electronic file in NAUPA Standard Format. Form 652 (Schedule A) MUST be completed if you are reporting 10 items or less and are not submitting an electronic Name (Holder)Federal ID NumberState / Date of IncorporationPrior Name - If Entity Name has changedPrevious Holder - If you are a successor to a previous holderContact Person - For questions from Unclaimed Property staffNameDirect Telephone NumberE-mail AddressMailing AddressCityStateZIP codeCustomer Contact - For use by owners of reported propertyName Same as Contact PersonTelephone NumberE-mail AddressSummary of Abandoned Property ReportedTotal amount of properties under $50$In order to facilitate customer service, we request that, when possible, you do not aggregate these funds in your reportTotal amount of properties over $50 with known owners$Total amount of properties with unknown owners$Total Report Amount$4a. Remittance must accompany report. 4b. I have attached a true and correct list (Schedule A) of individual owners and properties, in accordance with 44-307(B),Reporting software is available for free download on our website I have reviewed and understand the State of Arizona payment protocols (see the Arizona Unclaimed Property Reporting Manual). The relationship codes reported for each property will allow accurate payment to the reported Written notice has been sent to the owners of all properties being reported/remitted in accordance with 44-307(E).FOR DEPARTMENT USE ONLYDeposit AmountDATE STAMPARIZONA FORM650ASTOPDo NoT STAPLE REPoRT/CHECKSSToPArizona Department of Revenue Unclaimed Property SectionREPORT OF ABANDONED SECURITIESDATE STAMPI hereby certify that I have the authority to execute this report of Unclaimed Property on behalf of the above named holder. I declare under penalty of perjury that the foregoing information, the information set forth in the schedules, and all documentation I have or will provide is true and complete. Print Name Signature DateMAIL TO: Arizona Unclaimed Property Section 1600 West Monroe Street, Division Code 10 Phoenix, AZ 85007ADOR 10756 (3/14)If you are remitting abandoned property, please use Arizona Form 650AIf you are remitting safe deposit box contents, please use Arizona Form 650C12345ARIZONA FORM650BIf your report contains more than 10 items you MUST submit an electronic file in NAUPA Standard Format. Form 652 (Schedule A) MUST be completed if you are reporting 10 items or less and are not submitting an electronic Name (Holder)Federal ID NumberState / Date of IncorporationPrior Name - If Entity Name has changedPrevious Holder - If you are a successor to a previous holderContact Person - For questions from Unclaimed Property staffSecurities ContactNameNameDirect Telephone NumberDirect Telephone NumberE-mail AddressE-mail AddressMailing AddressMailing AddressCityStateZIP codeCityStateZIP codeCustomer Contact - For questions from owners of reported propertyName Same as Contact PersonTelephone NumberE-mail AddressSummary of Abandoned Securities ReportedTotal amount of properties under $50$In order to facilitate customer service, we request that, when possible, you do not aggregate these funds in your reportTotal amount of properties over $50 with known owners$Total amount of properties with unknown owners$Total Report Amount$Shares of Stock: Issue NameSent DTC Yes NoCUSIP of SharesYou are required to attach a verification statement to confirm transfer of shares. Remittance must accompany reinvestment plans will not be accepted in book entry form. Each owner s account must be converted into whole the Arizona Unclaimed Property Reporting Manual 651 for detailed questions about the report or transfer of securities, call (602) 716-6032. For mutual funds questions, call (602) I have attached a true and correct list (Schedule A) of individual owners and properties, in accordance with 44-307(B),Reporting software is available for free download on our website I have reviewed and understand the State of Arizona payment protocols (see the Arizona Unclaimed Property Reporting Manual). The relationship codes reported for each property will allow accurate payment to the reported Written notice has been sent to the owners of all properties being reported/remitted in accordance with 44-307(E).FOR DEPARTMENT USE ONLYDeposit Amount12345ARIZONA FORM650CADOR 10757 (9/10)Previous ADOR 17-5623Entity Name (Holder)Mailing AddressCity4c. Written notice has been sent to the owners of all properties being reported/remitted in accordance with 44-307(E).NameTitleNameDirect Telephone NumbersserddA liam-EsserddA liam-EArizona Department of Revenue Unclaimed Property SectionREPORT OF SAFE DEPOSIT BOX CONTENTSDATE STAMPCustomer Contact (for use by owners of reported property)Same as Holder ContactTelephone NumberE-mail AddressSummary of Safe Deposit Box Contents ReportedIf you are remitting abandoned property, please use Arizona Form 650AIf you are remitting securities, please use Arizona Form 650BPrevious Holder (If you are a successor to a previous holder of the property)Number of Safe Deposit Boxes Reported/RemittedAfter submitting the report, contact the Unclaimed Property Vault Specialist to schedule not send safe deposit box contents without a report confi rmation number from the Unclaimed Property Vault a copy of this report with the report confi rmation number you received to the safe deposit box contents you address:Arizona Unclaimed Property Section1600 West Monroe Street, Phoenix, AZ 85007 etaD erutangiS emaN tnirPI hereby certify that I have the authority to execute this report of Unclaimed Property on behalf of the above named holder. I declare under penalty of perjury that the foregoing information, the information set forth in the schedules, and all documentation I have or will provide is true and complete. Acting as the authorized representative of the entity named above, I agree to indemnify the State of Arizona and hold it harmless against any and all claims, judgments, decrees, costs, expenses (including reasonable attorney fees) or any other loss which either the State or owner might sustain in situations where the above described property is destroyed, damaged, lost, or stolen during the delivery of the property to the State of Arizona by a third Confi rmation Number (see no. 3 below)Holder Contact (for use by Unclaimed Property staff) Transfer/Reporting Agent Contact (for use by Unclaimed Property staff)TitleNameDirect Telephone NumbersserddA gniliaMsserddA gniliaMytiCytiCedoc PIZetatSedoc PIZetatSFederal ID NumberFOR DEPARTMENT USE redloH .oN tpieceR .oN tropeR tnuomA kcehC .oN kcehC ZIP CodeState4a. I have attached a true and correct list (Schedule A) of individual owners and properties, in accordance with 44-307(B).Reporting software is available for free download on our website I have reviewed and understand the State of Arizona payment protocols (see the Arizona Unclaimed Property Reporting Manual) The relationship codes reported for each property will allow accurate payment to the reported Department of Revenue Unclaimed Property SectionNEGATIVE REPORT OF ABANDONED PROPERTYDATE STAMPADOR 11022 (3/14)Previous ADOR 17-2009MAIL TO: Arizona Department of Revenue Unclaimed Property Unit1600 W Monroe Street, Division Code 10 Phoenix, AZ 85007For assistance in the Phoenix area: (602) 364-0380 or outside the Phoenix area toll free: (877) 492-9957To speak to the reporting specialist: (602) 716-6031Fax: (602) 716-7997 Email: FORM650DEntity Name (Holder)Federal ID NumberState / Date of IncorporationPeriod CoveredPrior Name (if Entity Name has changed)Previous HolderHolder Contact (for use by Unclaimed Property staff)NameDirect Telephone NumberE-mail AddressMailing AddressCityStateZIP codeThe undersigned declares under penalty of perjury, that to the best of his/her knowledge and belief, the above named entity has no property which would be presumed abandoned under the Arizona Uniform Unclaimed Property Act for the period covered as stated and that he/she is duly authorized to execute this report. Print Name Signature DateArizona Department of Revenue Unclaimed Property SectionREPORT OF ABANDONED PROPERTY - SCHEDULE AADOR 11017 (3/14)ARIZONA FORM652This Schedule A must accompany a Form 650A or 650B and should be utilized ONLY if your report contains 10 items or NAMEFederal Employer Identification Number (FEIN)Grand Total Remitted$Item noAccount #Check #NAUPA property typeCash amount remittedInterest rateLast activity dateOwner s last nameOwner s first name / middle initial Owner s mailing addressCity, state, ZIP codeCountryOwner s Tax ID (SSN or EIN) Owner s date of birthNAUPA relationship codeFee/Drilling costNo. of shares remittedSecurity/Mutual Fund nameCUSIP of DeathCOMPLETE THE FIELDS BELOW IF THERE IS MORE THAN ONE OWNER FOR THIS PROPERTYAdditional owner s last nameAdditional owner s first name / middle initial Additional owner s Tax ID (SSN or EIN) Relationship codeAdditional owner s date of birthAdditional owner s date of deathOther information availableAdditional owner s last nameAdditional owner s first name / middle initial Additional owner s Tax ID (SSN or EIN) Relationship codeAdditional owner s date of birthAdditional owner s date of deathOther information availableItem noAccount #Check #NAUPA property typeCash amount remittedInterest rateLast activity date (required)Owner s last nameOwner s first name / middle initial Owner s mailing addressCity, state, ZIP codeCountryOwner s Tax ID (SSN or EIN) Owner s date of birthNAUPA relationship codeFee/Drilling costNo. of shares remittedSecurity/Mutual Fund nameCUSIP of DeathCOMPLETE THE FIELDS BELOW IF THERE IS MORE THAN ONE OWNER FOR THIS PROPERTYAdditional owner s last nameAdditional owner s first name / middle initial Additional owner s Tax ID (SSN or EIN) Relationship codeAdditional owner s date of birthAdditional owner s date of deathOther information availableAdditional owner s last nameAdditional owner s first name / middle initial Additional owner s Tax ID (SSN or EIN) Relationship codeAdditional owner s date of birthAdditional owner s date of deathOther information availablePAGE OF 1234ARIZONA FORM670Arizona Department of RevenueHOLDER REIMBURSEMENT REQUEST FORMADOR 17-2022 (9/09)Holder NameOwner s Street AddressOwner s City or TownOwner s ZIP CodeOwner s StateI depose and swear under oath that I am authorized to make this affi davit as a duly authorized offi cer. Based upon personal knowledge, the information provided by the reporting institution (holder) to substantiate payment to the owner or reinstatement of the remitted account is true and correct. By demonstrating that the owner, or his/her personal representative was paid or reinstated, I hereby certify this claim for reimbursement is valid and just. Upon payment by the Arizona Department of Revenue of the reimbursement described above, the reporting institution (holder), herein named, agrees to indemnify and hold harmless the State of Arizona, its employees and agents from any and all liability, claims, demands, losses, suits, or actions, arising from or related to any other party who hereafter asserts or attempts to establish right to payment of the above described funds to the extent of the value of the property so paid or YearOwner s Name as Indicated on ReportMAIL TO: Arizona Department of Revenue Unclaimed Property Unit PO Box 29026 Phoenix, AZ 85038-9026For assistance in the Phoenix area: (602) 364-0380 or outside the Phoenix area toll free: (877) 492-9957Fax: (602) 542-2089 Public Signature fo ytnuoC fo etatS(Affi x Seal Here) etaD erutangiSSubscribed and Affi :yb em erofeb demr . 02 , fo yad sihtAdditional Owner as Indicated on ReportReport AmountProperty Type CodeAggregateProperty AmountYESNOProperty DescriptionCity or TownMailing AddressTax Identifi cation NumberZIP CodeStateeltiTnosreP tcatnoCsserddA liam-ErebmuN enohpeleTOwner InformationHolder InformationVerifi cation for Period Ended:Arizona Department of Revenue Unclaimed Property Section1600 W Monroe Phoenix, AZ 85007REPORT OF ABANDONED PROPERTYVerifi cation and ChecklistEvery person, corporation or other business association, banking or fi nancial organization, life insurance corporation, utility, court or public authority must complete the following checklist before fi ling their Arizona Annual Report of Property Presumed Abandoned. This checklist includes by way of illustration, but not limitation, those items which are covered by Section 44-301 et seq of the Arizona Revised Uniform Unclaimed Property Act. All of the following types of property, with the exception of travelers checks must be reported if they have remained unclaimed for one or more years. Travelers checks should be held fi fteen (15) years. Please completethe checklist by checking the box next to each applicable item. ACCOUNT BALANCES A. Checking accounts B. Savings accounts C. Matured certifi cates of deposit or savings certifi cates D. Christmas Club accounts E. Money on deposit to secure funds F. Security deposits G. Unidentifi ed deposits H. Suspense accounts I. Any sum owing to a shareholder, certifi cate holder, member, bond holder or other security holder, or participating member of a cooperative, such as: 1. dividends 2. interest 3. principal payments 4. equity payments 5. profi ts 6. other distributions J. Escrow fundsTRUST, INVESTMENT AND ESCROW ACCOUNTS A. Paying agent accounts B. Unclaimed dividends C. Funds held in a fi duciary capacity D. Funds paid toward the purchase of shares, or interest in a fi nancial or business organization E. Funds received for redemption of stocks and bonds F. Stocks G. Bonds H. Any other certifi cates of ownership I. Suspense liabilitiesUTILITIES A. Utility deposits B. Membership fees C. Refunds or rebatesCOURT DEPOSITS A. Escrow funds B. Condemnation awards C. Missing heirs funds D. Suspense accounts E. Victim s restitution F. Any other type of deposit made with a court or public authorityTANGIBLE PROPERTY A. Contents of safe deposit boxes B. Contents of any other safekeeping repository C. Other tangible propertyMISCELLANEOUS CHECKS AND INTANGIBLE PERSONAL PROPERTY HELD IN THE ORIDINARY COURSE OF BUSINESS A. Wages, payroll or salary B. Commissions C. Expense checks D. Workman s Compensation benefi ts E. Pension checks F. Credit checks or memos G. Payments for goods and services H. Customer overpayments I. Unidentifi ed remittance J. Unrefunded overcharges K. Accounts payable L. Credit balances - accounts receivable M. Discounts due N. Refunds O. Unredeemed gift certifi cates P. Vendor checks Q. Mineral proceeds R. Royalties S. Any other miscellaneous outstanding checks T. Any checks that have been written off to income or surplus U. Any other miscellaneous intangible personal propertyOFFICIAL CHECKS A. Certifi ed checks B. Cashier s checks C. Registered checks D. Treasurer s checks E. Drafts F. Warrants G. Money orders H. Travelers checks I. Foreign exchange J. Any other offi cial checks or exchange itemsDISSOLUTIONS A. All property distributable in the course of voluntary or involuntary dissolution or liquidation which is unclaimed within one year after the date for fi nal distribution is presumed A. Amounts due and payable under terms of insurance policies B. Claim payments C. Drafts unpresented for payment D. Matured whole life, term or endowment insurance policies or annuity or supplementary contracts E. Other amounts due under policy termsADOR 11017 (8/11)
State of Arizona - azunclaimed.gov
651 State of Arizona Unclaimed Property Reporting Manual Report & Instructions 2017 (602) 716-6031 or (602) 716-6032 (602) 716-7997 ...
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