safe deposit box contents - Tennessee Department of Treasury

STATE OF TENNESSEE • TREASURY DEPARTMENTUnclaimed Property DivisionP.O. Box 198649 • Nashville, Tennessee 37219-8649 • (615) 253-5362E-mail: UCP.Holders@tn.govwww.tn.gov/treasury/unclaimIII. ANNUAL REPORT OF UNCLAIMED PROPERTYVERIFICATION & AFFIDAVIT OF SAFE DEPOSIT ITEMS FOR YEAR ENDED DECEMBER 31, ______A. Holder # ______________________________________NameAddress________________________________________________________________________________________________________________________________________________________E-Mail ______________________________________ State of Incorporation ______________________________Fed Tax ID # ______________________________________Date of Incorporation ______________________________Name of contact person or department designated to respond to safe deposit box unclaimed property inquiries:Name ______________________________________ ________________________________________________Telephone ______________________________________ ________________________________________________E-Mail ______________________________________ ________________________________________________B. Type of company: _______________________________________________________________________________________C. Type of report: Initial Content Report Sale proceeds and disposition of previously reported contentsMethod of report: Compact Disk Diskette PaperD. Total cash remitted (make check payable to "State Treasurer of Tennessee"): ________________________________________E. Total shares of physical securities remitted: _______________________________________________________________F. Face amount of bonds remitted: _______________________________________________________________G. Amount deposited to lessee's existing account: _______________________________________________________________Notarized Signature RequiredH. VERIFICATION AND AFFIDAVIT: The undersigned,____________________________________________________,declares under penalty of perjury, that, to the best of (his) (her) knowledge, the foregoing report and supporting records contain afull, true and complete report of unclaimed property now in the possession or under the control of the holder, which is presumedabandoned in accordance with the provisions of Tennessee Code Annotated, Sections 66-29-101 through 66-29-153. I am dulyauthorized to attest to this.Date __________________________________________ ________________________________________________Signature of Chief Financial OfficerState of __________________________________________ ________________________________________________TitleCity/County _______________________________________ SEALSubscribed and sworn to before me this _________ day of ___________________ 20____Notary Public ______________________________________TR-0392 (Rev. 10/05) SAFE DEPOSIT CONTENT REPORT DUE MAY 1RDA 1153Proceeds/Disposition report due 60 days after sale/disposition.