ESCHEAT AND UNCLAIMED PROPERTY PROGRAM by umsymums37

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									State of North Carolina Department of State Treasurer Unclaimed Property Program 325 North Salisbury Street Raleigh, North Carolina 27603-1385 (919) 508-1000 www.nccash.com

Unclaimed Property Verification and Checklist
Reporting Period July 1, 2007 through June 30, 2008 Due November 1, 2008 GOVERNMENTAL AGENCIES ONLY THIS FORM MUST BE COMPLETED, NOTARIZED & SUBMITTED WITH REMITTANCE

PLEASE TYPE OR USE BLACK INK

Holder Name: Mailing Address: City: State: Zip:

Holder Identification Number: Federal Identification Number: Date of Incorporation: Telephone Number: ( ) Company E-mail Address: Nature of Business:

State of Incorporation: Number of Employees:

Every person, corporation, or other business association, banking or financial organization, insurance company, utility, court or public authority, etc. reporting unclaimed property must complete this form (ASD-159) and it should be filed with the Annual Report of Unclaimed Property (ASD-21) and/or Report of Unclaimed Securities (ASD-215) and/or Abandoned Tangible Personal Property (ASD-127). This checklist includes, but is not limited to those items that are covered by the North Carolina Escheat and Unclaimed Property Law, North Carolina General Statute 116B.

CHECKLIST COMPLETION
Please complete the checklist on the back by checking “YES” by each item that is being reported. Each item checked “Yes” must be enumerated in the Report of Unclaimed Property (Form ASD-21).

LATE FILING INTEREST PENALTY
In addition to any other penalties, any holder who files after November 1 shall remit interest at the rate pursuant to North Carolina General Statute 116B-77, currently 5%. The interest penalty is computed as follows: Total amount of property reportable X # of days late/365 X 5%= Interest Penalty

CERTIFICATION AND VERIFICATION
As the person authorized to bind this holder, I, being duly sworn, certify the attached report to be true and properly prepared and examined for correctness, ensuring that all property eligible to be remitted is included in this return, and the property reported has been held for the period required by North Carolina General Statute 116B-53. Further, I certify that notices pursuant to North Carolina General Statute 116B-59 were sent to the owners at their last known address. This notarized certification is an affidavit attesting that the holder has complied with North Carolina General Statute 116B-59. Report Total

State of Subscribed and sworn to before me this Notary Public: My Commission expires:

County of day of State of County of ,

Name-Print:
Interest Penalty

$ $ Total Remittance $

Title: Signature:

(SEAL) OFFICE USE ONLY
DISKETTE
ASD-159G Revised 06-06-08

CD CUSIP

LOADED

KEYED SYMBOL

BALANCED CERTIFICATE

COMMITTED DTC DATE CUSTODIAN

STOCK ID

Class Code ACCOUNT BALANCES DUE AC01 Checking Accounts AC02 Savings Accounts AC03 Matured CD or Savings Cert AC04 Christmas Club Funds AC05 Money-Deposit to Secure Funds AC06 Security Deposits AC07 Unidentified Deposits AC08 Suspense Accounts AC09 Individual Retirement Accounts AC99 Aggregate Account Balances < $50 UNCASHED CHECKS Cashier’s Checks Certified Checks Registered Checks Treasurer’s Checks Drafts Warrants Money Orders Traveler’s Checks Foreign Exchange Checks Expense Checks Pension Checks Credit Checks or Memos Vendor Checks Checks Written Off to Income Other Outstanding Official Checks CD Interest Checks Aggregate Uncashed Checks < $50

Dormant Period

Class Code MINERAL PROCEEDS & MINERAL INTERESTS MI01 Net Revenue Interest MI02 Royalties MI03 Overriding Royalties MI04 Production Payments MI05 Working Interest MI06 Bonuses MI07 Delay Rentals MI08 Shut-In Royalties MI09 Minimum Royalties MI99 Aggregate Mineral Interests < $50

Dormant Period

1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1

CK01 CK02 CK03 CK04 CK05 CK06 CK07 CK08 CK09 CK10 CK11 CK12 CK13 CK14 CK15 CK16 CK 99

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SAFE DEPOSIT BOXES & SAFEKEEPING SD01 *Safe Deposit Box Contents SD02 *Safekeeping/Loan Collateral SD03 *Other Tangible Property SD99 Aggregate Safe Deposit Boxes & Safekeeping Items < $50 COURT DEPOSITS Escrow Funds Condemnation Awards Missing Heirs’ Funds Suspense Accounts Other Court Deposits Real Property Proceeds Cash Bonds Partial Payments Judgments Trust Funds Aggregate Court Deposits < $50

1 1 1 1

MISCELLANEOUS CHECKS & INTANGIBLE PERSONAL PROPERTY MS01 Wages, Payroll, Salary MS02 Commissions MS03 Workers’ Compensation Benefits MS04 Payment for Goods & Services MS05 Customer Overpayments MS06 Unidentified Remittances MS07 Unrefunded Overcharges MS08 Accounts Payable MS09 Credit Balances (3 Retail/5 Other) MS10 Discounts Due MS11 Refunds Due MS12 Unredeemed Gift Certificates MS13 Unclaimed Loan Collateral MS14 Pension & Profit Sharing Plans (IRA, KEOGH) MS15 Dissolution or Liquidation MS16 Misc Outstanding Checks MS17 Misc Intangible Prop MS18 Suspense Liabilities MS19 Layaway Deposits & Payments MS20 Rents MS99 Aggregate Misc Checks & Intangible Personal Property < $50 SECURITIES SC01** Dividends SC02** Interest (Bond Coupons) SC03 Principal Payments SC04** Equity Payments SC05** Profits SC06 Funds Paid to Purchase Shares SC07 Funds For Stocks & Bonds SC08 Shares of Stock (Returned by Post Office) SC09 Cash for Fractional Shares SC10 Unexchanged Stock & Fractional Shares of Successor Corp SC11 Other Cert of Ownership SC12** Underlying Shares or Other Outstanding Certificates SC13 Funds for Liquidation Redemption of Surrendered Stocks or Bonds SC14 Debentures SC15 US Govt Securities SC16 Mutual Fund Shares SC17 Warrants (Rights) SC18 Matured Bond Principal SC19 Dividend Reinvestment Plans SC20 Credit Balances SC99 Aggregate Security Related Cash < $50 UTILITIES Utility Deposits Membership Fees Refunds or Rebates Capital Credit Distributions Aggregate Utility Property < $50

1 1 1 1 1 1 1 1 1 1 1 ***1 1 1 1 1 1 1 1 1 1

CT01 CT02 CT03 CT04 CT05 CT06 CT07 CT08 CT09 CT10 CT99

1 1 1 1 1 # 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

DEMUTUALIZATION DM01 Cash DM02 Stock DM99 Aggregate Demutualization Property < $50 INSURANCE Individual Policy Benefits or Claim Payments Group Policy Benefits or Claim Payments Proceeds Due Beneficiaries Proceeds from Matured Policies Endowments or Annuities Premium Refunds Unidentified Remittances Other Amounts Due Under Policy Terms Agent Credit Balances Aggregate Insurance Property < $50

1 1 1

IN01 IN02 IN03 IN04 IN05 IN06 IN07 IN08 IN99

1 1 1 1 1 1 1 1 1

UT01 UT02 UT03 UT04 UT99

1 1 1 1 1

TRUST, INVESTMENT AND ESCROW ACCOUNTS TR01** Paying Agent Accounts TR02** Undelivered/Uncashed Dividends TR03 Funds held in Fiduciary Capacity TR04 Escrow Accounts TR05 Trust Vouchers TR99 Aggregate Trust Property < $50

1 1 1 1 1 1

MISCELLANEOUS ZZZZ Properties Not Identified Above

1

* ** *** #

This property should be reported on Form ASD-127 prior to submitting the property. Specify Date Range (i.e. the date of the first and last payments) on “Periodic Payments” (i.e. outstanding dividend checks) if multiple payments of same property type are being reported for a single property owner. 60% of the unredeemed portion of the face value if an expiration period is displayed on the certificate. Gift certificates with no expiration date, or a statement that the expiration date does not apply in North Carolina, do not escheat. Under Court Supervision


								
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