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                                                                         Unclaimed Property Division
                                                                         P.O. Box 17161 
                                                                         Baltimore, Maryland 21297-1161 

                                  Maryland Unclaimed Property Report 

HOLDER:                                                                  HOLDER NUMBER:

FOR THE YEAR ENDED:                                                      DUE DATE: 

A. If you have NO unclaimed property to
report for this period, check here:              STATE OF INCORPORATION: 

B. If you DO have unclaimed property to report:

1. Enter total dollar amount of all accounts LESS than $100.00 here:    $
2. Use FORM COM/CD 919 to report:
          ●   Individual accounts $100.00 and GREATER
          ●   Securities (stocks, bonds, certificates, etc.)
          ●   Safe Deposit Boxes
          ●   10 Accounts or less

Enter total number of unclaimed accounts $100.00 and GREATER listed on FORM COM/CD 919 here: 

IMPORTANT:     We will notify owners to call you about this report, at: 

, unless you give a preferred telephone number here: 

I declare under penalty of perjury that this report (including any accompanying schedules and statements) 
has been examined by me and to the best of my knowledge is a true and complete report. 

               Signature                             Title                             Date 

Federal I.D. Number:

Name of Company or Corporation: 

Mailing Address: 

Location Address: 

City & State:                                                            Zip Code: 

Contact Person:                                             Telephone Number for Contact Person: 

E-mail for Contact Person:
COD/CD 918 08/2023
                                    (410) 767-1700 OR Toll Free 1(800) 782-7383
                                                 FAX:  (410) 333-7150