ARIZONA FORM                     Arizona Department of Revenue • Unclaimed Property Section

        652                      REPORT OF ABANDONED PROPERTY - SCHEDULE A
                                 This Schedule A must accompany a Form 650A or 650B  
                                 and should be utilized ONLY if your report contains 10 items or less.

HOLDER NAME                                  Federal Employer Identification Number (FEIN)              Grand Total Remitted

                                                                                                        $
Item no Account #                                          Check #                                                   NAUPA property type

Cash amount remitted                         Interest rate                                    Last activity date

Owner’s last name                            Owner’s first name / middle initial Owner’s mailing address

City, state, ZIP code                        Country               Owner’s Tax ID (SSN or EIN) Owner’s date of birth NAUPA relationship code

Fee/Drilling cost     No. of shares remitted Security/Mutual Fund name                        CUSIP no.              Date of Death

                  COMPLETE THE FIELDS BELOW IF THERE IS MORE THAN ONE OWNER FOR THIS PROPERTY
Additional owner’s last name                 Additional owner’s first name / middle initial Additional owner’s Tax ID (SSN or EIN) Relationship code

Additional owner’s date of birth Additional owner’s date of death  Other information available

Additional owner’s last name                 Additional owner’s first name / middle initial Additional owner’s Tax ID (SSN or EIN) Relationship code

Additional owner’s date of birth Additional owner’s date of death  Other information available

Item no Account #                                          Check #                                                   NAUPA property type

Cash amount remitted                         Interest rate                                    Last activity date (required)

Owner’s last name                            Owner’s first name / middle initial Owner’s mailing address

City, state, ZIP code                        Country               Owner’s Tax ID (SSN or EIN) Owner’s date of birth NAUPA relationship code

Fee/Drilling cost     No. of shares remitted Security/Mutual Fund name                        CUSIP no.              Date of Death

                  COMPLETE THE FIELDS BELOW IF THERE IS MORE THAN ONE OWNER FOR THIS PROPERTY
Additional owner’s last name                 Additional owner’s first name / middle initial Additional owner’s Tax ID (SSN or EIN) Relationship code

Additional owner’s date of birth Additional owner’s date of death  Other information available

Additional owner’s last name                 Additional owner’s first name / middle initial Additional owner’s Tax ID (SSN or EIN) Relationship code

Additional owner’s date of birth Additional owner’s date of death  Other information available

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