ARIZONA FORM Arizona Department of Revenue • Unclaimed Property Section

                            650A                     REPORT OF ABANDONED PROPERTY

                                         If 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 file.
                                                                                                                                       DATE STAMP
                                                                   If you are remitting securities, please use Arizona Form 650B
                                                      If you are remitting safe deposit box contents, please use Arizona Form 650C
                              Entity Name (Holder)

                              Federal ID Number                                           State / Date of Incorporation

                            1
DO NOT STAPLE REPORT/CHECKS   Prior Name - If Entity Name has changed                     Previous Holder - If you are a successor to a previous holder

STOP                          Contact Person - For questions from Unclaimed Property staff
                              Name

                              Direct Telephone Number

                              E-mail Address

                              Mailing Address

                              City                                                                                                   State ZIP code

                              Customer Contact - For use by owners of reported property
                              Name                     Same as Contact Person            Telephone Number

                              E-mail Address
                            2
                              Summary of Abandoned Property Reported
                              Total amount of properties under $50                        In  order  to  facilitate  customer  service,  we  request  that,  when 
                              $                                                           possible, you do not aggregate these funds in your report
                              Total amount of properties over $50 with known owners Total amount of properties with unknown owners   Total Report Amount
                            3 $                                         $                                                            $
                              4a. Remittance must accompany report. 
                              4b. I have attached a true and correct list (Schedule A) of individual owners and properties, in accordance with A.R.S. § 44-307(B),
                                Reporting software is available for free download on our website www.azunclaimed.gov.
                            4 4c. 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 owners.
                              4d. Written notice has been sent to the owners of all properties being reported/remitted in accordance with A.R.S. § 44-307(E).
                              I 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.

                            5

                              Print Name                               Signature                                                      Date
                                                                                          Print Reset form
                              MAIL TO: Arizona Unclaimed Property Section   1600 West Monroe Street, Division Code                 10   Phoenix, AZ 85007
                                                                   FOR DEPARTMENT USE ONLY
                                         Deposit No.                                                      Receipt No.

                                            Check No.                                                     Check Amount

ADOR 10755 (3/14)