Office of the Vermont State Treasurer – Unclaimed Property Division th 109 State St., 4 Floor • Montpelier, VT 05609-6200 │ Phone: 802.828.2407 • Fax: 802.828.2884 tre.upcompliance@vermont.gov UNCLAIMED ROPERTY NNUAL OMPLIANCE EPORT OVER HEET P A C R C S (This Sheet MUST Accompany Report) Submission Date HOLDER NAME REPORT DUE ATE D : MAY 1, 20 REPORTING PERIOD :AN J . 1, 20 TO DEC . 31, 20 1. Federal ID No. Contact Person Title Address E-mail Address City Telephone State Zip State of Incorporation Date of Incorporation PREVIOUS HOLDER NAME If a successor to a previous holder of the property, or if your organization name changed, indicate original holder name and address – or name and address under which your organization previously filed unclaimed property reports in Vermont. Name Address Characteristic Applicable to Business ☐ Total Assets ☐ Premiums Written ☐ Yearly Deposits ☐ Sales/Gross Receipts Range (millions) ☐ $0 – 10 ☐ $11 - 25 ☐ $26 - 50 ☐ $51 – 100 ☐ $101+ Employees ☐ 1 - 20 ☐ 21 - 50 ☐ 51 - 100 ☐ 101 - 250 ☐ 251 - 500 ☐ 501 - 900 ☐ 901+ 2. Was an unclaimed property report filed last year for this holder? ☐ Yes ☐ No If No, please explain: 2A. Was a negative unclaimed property report filed last year for this holder? ☐ Yes ☐ No 3. Summary classification of property being reported/remitted: TOTALS A. Accounts equal to $25 or less ( # OF ACCOUNTS WITHIN AGGREGATE TOTAL) $ B. Accounts more than $25 (owner name is unknown) $ C. Accounts more than $25 (owner name is known) $ TOTAL FINANCIAL PROPERTY REMITTED (all accounts) $ D. Total SHARE(s) Remitted Affidavit of Due Diligence Safe Deposit Box Details The undersigned (print name) Estimated Delivery Date declares that the Due Diligence mailing was performed in accordance with §1247(g) V.S.A. Title 27, Chapter 14 on (enter number of letters mailed) accounts. Quantity of Boxes to be Delivered Signature Title The undersigned, (print name) , being duly sworn on oath, deposes and says that he/she has caused to be prepared and has examined this report of pages, totaling $ , as to property presumed abandoned under the Vermont Statutes Annotated, Title 27, Chapter 14, for the year ending as stated and that he/she, acting as duly authorized representative of , declares, in accordance with Title 13, Chapter 67, Section 3016 ‘False Claims’, that, to the best of his/her knowledge and belief, said report is a true and complete statement of all abandoned property held or owing by the HOLDER at the close of business on this date, except such items as have since said date ceased to be abandoned. Print Name Signature Title Subscribed and sworn before me on this day of , in the year NOTARY: M CY OMMISSION EXPIRES: FOR UNCLAIMED PROPERTY DIVISION USE ONLY Holder ID/Year/Suffix Check Amount Deposit Date Balanced By Holder Label Make check payable to: Vermont State Treasurer's Office Mail to: 109 State St., 4th Floor │ Montpelier, VT 05609-6200 |
Office of the Vermont State Treasurer – Unclaimed Property Division th 109 State St., 4 Floor │Montpelier, VT 05609-6200 │ Phone: 802.828.2407 • Fax: 802.828.2884 UNCLAIMED ROPERTY NNUAL OMPLIANCE EPORTP A C R VERIFICATION HECK IST C L Holder Name Verification for the Period Ended Every person, corporation or other business association, banking or financial organization, life insurance corporation, utility, court, or public authority must complete this Verification Check List as part of the annual reporting of unclaimed property. This checklist illustrates, without limitation, those items covered by Chapter 14, Title 27 of the Vermont Statutes. With the exception of travelers checks and money orders, the property types shown below must be reported if unclaimed for one or more years. Travelers checks should be held fifteen (15) years and money orders seven (7) years. Check the box next to each applicable item. Each checked item must be accounted for on the detail of the Annual Report of Unclaimed Property. ACCOUNT BALANCES PAYROLL ,XPENSE E , MISC .HECKSC AND NTANGIBLE I ERSONALP PROPERTY HELD IN COURSE OF RDINARY O USINESSB Checking accounts Savings accounts Wages, payroll or salary Matured certificates of deposit or savings certificates Commissions Christmas Club accounts Expense checks Money on deposit to secure funds Worker’s Compensation benefits Security deposits Pension checks Unidentified deposits Credit checks or memos Suspense accounts Payments for goods and services Sums owing to a shareholder, certificate holder, bond holder or other Customer overpayments security holder, or participating member of a cooperative, such as: Unidentified remittance dividends Un-refunded overcharges interest Accounts payable principal payments Credit balances - accounts receivable equity payments Discounts due profits Refunds other distributions Unredeemed gift certificates Escrow funds Vendor Checks Mineral proceeds COURT DEPOSITS Royalties Escrow funds Any other miscellaneous outstanding checks Condemnation awards Any checks written off to income or surplus Missing heir funds Any other miscellaneous intangible personal property Suspense accounts Victim’s restitution TANGIBLE ROPERTYP Any other type of deposit made with a court or public authority Safe deposit box contents Any other safekeeping repository contents DISSOLUTIONS Other tangible property Property distributable in the course of voluntary or involuntary dissolution or liquidation which is unclaimed within one year after the TRUST ,NVESTMENTI AND SCROW E CCOUNTSA date for final distribution is presumed abandoned. Paying agent accounts Unclaimed dividends INSURANCE Funds held in a fiduciary capacity Amounts due and payable under terms of insurance policies Funds paid toward the purchase of shares, or interest in a Claim payments financial or business organization Drafts not presented for payment Funds received for redemption of stocks and bonds Matured whole life, term or endowment insurance policies or annuity Stocks or supplementary contracts Bonds Other amounts due under policy terms Any other certificates of ownership Suspense liabilities OFFICIAL HECKSC Certified checks UTILITIES Cashier’s checks Utility deposits Registered checks Membership fees Treasurer’s checks Refunds or rebates Drafts Warrants Money orders Travelers checks Foreign exchange Other official checks or exchange items Rev: 10.12.16 |