Enlarge image | ARIZONA FORM Arizona Department of Revenue • Unclaimed Property Section 650D NEGATIVE REPORT OF ABANDONED PROPERTY DATE STAMP Entity Name (Holder) Federal ID Number State / Date of Incorporation 1 Period Covered Prior Name (if Entity Name has changed) Previous Holder Holder Contact (for use by Unclaimed Property staff) Name Direct Telephone Number E-mail Address Mailing Address City State ZIP code The undersigned declares under penalty of perjury, that to the best of his/her knowledge and belief, the above named entity has no property which would be presumed abandoned under the Arizona Uniform Unclaimed Property Act for the period covered as stated and that he/she is duly authorized to execute this report. 2 Print Name Signature Date Print Reset form MAIL TO: Arizona Department of Revenue Unclaimed Property Unit 1600 W Monroe Street, Division Code 10 Phoenix, AZ 85007 For assistance in the Phoenix area: (602) 364-0380 or outside the Phoenix area toll free: (877) 492-9957 To speak to the reporting specialist: (602) 716-6031 Fax: (602) 542-2089 https://azdor.gov/unclaimed-property Email: ReportingUnclaimedProperty@azdor.gov ADOR 11022 (9/20) Previous ADOR 17-2009 |