Enlarge image
Office of the Vermont State Treasurer – Unclaimed Property Division
th
109 State St., 4 Floor • Montpelier, VT 05609-6200 │ Phone: 802.828.2407 • Fax: 802.828.2884
tre.upcompliance@vermont.gov
UNCLAIMED ROPERTY NNUAL OMPLIANCE EPORT OVER HEET P A C R C S
(This Sheet MUST Accompany Report)
Submission Date HOLDER NAME
REPORT DUE ATE D : MAY 1, 20 REPORTING PERIOD :AN J . 1, 20 TO DEC . 31, 20
1. Federal ID No. Contact Person Title
Address E-mail Address
City Telephone
State Zip State of Incorporation Date of Incorporation
PREVIOUS HOLDER NAME If a successor to a previous holder of the property, or if your organization name changed, indicate original holder name and
address – or name and address under which your organization previously filed unclaimed property reports in Vermont.
Name Address
Characteristic Applicable to Business ☐ Total Assets ☐ Premiums Written ☐ Yearly Deposits ☐ Sales/Gross Receipts
Range (millions) ☐ $0 – 10 ☐ $11 - 25 ☐ $26 - 50 ☐ $51 – 100 ☐ $101+
Employees ☐ 1 - 20 ☐ 21 - 50 ☐ 51 - 100 ☐ 101 - 250 ☐ 251 - 500 ☐ 501 - 900 ☐ 901+
2. Was an unclaimed property report filed last year for this holder? ☐ Yes ☐ No
If No, please explain:
2A. Was a negative unclaimed property report filed last year for this holder? ☐ Yes ☐ No
3. Summary classification of property being reported/remitted: TOTALS
A. Accounts equal to $25 or less ( # OF ACCOUNTS WITHIN AGGREGATE TOTAL) $
B. Accounts more than $25 (owner name is unknown) $
C. Accounts more than $25 (owner name is known) $
TOTAL FINANCIAL PROPERTY REMITTED (all accounts) $
D. Total SHARE(s) Remitted
Affidavit of Due Diligence Safe Deposit Box Details
The undersigned (print name) Estimated Delivery Date
declares that the Due Diligence mailing was performed in accordance with §1247(g)
V.S.A. Title 27, Chapter 14 on (enter number of letters mailed) accounts. Quantity of Boxes to be
Delivered
Signature Title
The undersigned, (print name) , being duly sworn on oath, deposes and says that he/she has caused
to be prepared and has examined this report of pages, totaling $ , as to property presumed abandoned under the
Vermont Statutes Annotated, Title 27, Chapter 14, for the year ending as stated and that he/she, acting as duly authorized representative of
, declares, in accordance with Title 13, Chapter 67, Section 3016 ‘False Claims’, that,
to the best of his/her knowledge and belief, said report is a true and complete statement of all abandoned property held or owing by the HOLDER
at the close of business on this date, except such items as have since said date ceased to be abandoned.
Print Name Signature Title
Subscribed and sworn before me on this day of , in the year
NOTARY: M CY OMMISSION
EXPIRES:
FOR UNCLAIMED PROPERTY DIVISION USE ONLY
Holder ID/Year/Suffix Check Amount Deposit Date Balanced By Holder Label
Make check payable to: Vermont State Treasurer's Office Mail to: 109 State St., 4th Floor │ Montpelier, VT 05609-6200
