Unclaimed Property Reporting Booklet - Washington State Digital ...

Washington StateDepartment of RevenueUnclaimed Property SectionPO Box 34053Seattle, WA 98124-1053(360) 705-6706Negative Reportfor Unclaimed Property Please print clearly and use black ink onlyAddress changeBusiness Name:Attn or in care of:Mailing Address:City, State, Zip:Report and Payment Due by November 1Washington Holder NumberFederal ID Number Report Year Sequence NumberDate & State of Incorporation UBI NumberPrimary Business ActivityDate Received (office use only)Contact Person:Name( )Telephone NumberE-mailNo Property to Report:Inactive Account:Close Account:Check here if you do not have any property to report, then complete the declaration below.Check here if you do not anticipate having property to report. NOTE: You will need torequest report forms, if you need to report in the future.Check here if your business is closing or is closed.Report Declaration:I declare that this report, including attachments, has been examined by me. I am duly authorized by the holder herein toexecute this report and that I believe said report is true, correct, and complete for the stated period.Signature Title DateNEGATIVE REPORT INSTRUCTIONSShaded are for the Department use only.Holder Reporting Number, Name and Address: Enter business name and address. This address will be used for future reports orcorrespondence regarding unclaimed property.Name and Address Change: Enter the correct name and address above. Attach a list of subsidiaries that are reporting under thesame holder name.Washington Holder Number: Enter your holder number. For first time reporters, leave blank. A holder number will be assigned.Federal ID Number (FEIN): Enter your nine digit FEIN.Current Year: Enter the current year.Date and State of Incorporation: Enter your date and state of incorporation.Unified Business Identifier (UBI): Enter your Washington State (UBI), if known.Primary Business Activity: Briefly describe your primary business activity.Contact Person: Enter the name, telephone number, and e-mail address of contact person.No Property to Report: Check this box if you have nothing to report for the reporting year.Inactive Account: You do not have property to report for this year and do not expect to report in the near future.Close Account: Check this box if your company has closed or merged with another company.Report Declaration: This report must be signed by an authorized individual.For assistance visit ucp.dor.wa.gov or call (360) 705-6706. To inquire about the availability of this document in an alternate format for the visually impaired, pleasecall (360) 705-6715. Teletype (TTY) users may call 1-800-451-7985.REV 80 0050 (06/25/08)Unclaimed Property Reporting Booklet 9