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) 716-7997   https://azdor.gov/unclaimed-property  Email: ReportingUnclaimedProperty@azdor.gov

ADOR 11022 (9/20)
Previous ADOR 17-2009