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                                                                          Unclaimed Property Unit 
                                                                          P.O. Box 17161 
                                                                          Baltimore, Maryland 21297-1161

                                  Maryland Unclaimed Property Report

HOLDER:                                                                   HOLDER NUMBER:

FOR THE YEAR ENDED:                                                       DUE DATE:

A.  If you have NO unclaimed property to 
  report for this period, check here:            STATE OF INCORPORATION:   Alabama

B.  If you DO have unclaimed property to report:

  1.  Enter total dollar amount of all accounts LESS than $100.00 here:  $
  2.  Use FORM COM/CD 919 to report: 
           ●  Individual accounts $100.00 and GREATER 
           ●  Securities (stocks, bonds, certificates, etc.)  
           ●  Safe Deposit Boxes 
           ●  10 Accounts or less

Enter total number of unclaimed accounts $100.00 and GREATER listed on FORM COM/CD 919 here:  

IMPORTANT:  We will notify owners to call you about this report, at: 

, unless you give a preferred telephone number here:

I declare under penalty of perjury that this report (including any accompanying schedules and statements)  
has been examined by me and to the best of my knowledge is a true and complete report.  
  
______________________________________               ____________________               ____________________ 
                Signature                            Title                              Date

Federal I.D. Number:

Name of Company or Corporation:

Mailing Address:

Location Address:

City & State:                                                              Zip Code:

Contact Person:                                               Telephone Number for Contact Person:

E-mail for Contact Person:
COD/CD 918  05/2016 
                                      (410) 767-1700 OR Toll Free 1(800) 782-7383 
                                                 FAX:  (410) 333-7150