Detail Report for Unclaimed Property

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					                           WARNING: To protect against the possibility of others accessing your confidential
             Washington State       information, do not complete these forms on a public workstation.
             Department of Revenue
             Unclaimed Property Section
             PO Box 34053
             Seattle, WA 98124-1053
                                                     Detail Report for Unclaimed Property                                                       Reset This Form
             (360) 705-6706

  Holder Name                                                                                   Report Year

  Holder Number
   Primary Owner Last Name                                      First Name                                         Middle Initial      Relation to 1st owner:


   Title                                              Date of Birth                               SSN/FEIN


   Complete Secondary Owner Information If There Is More Than One Owner For This Property

   Secondary Owner Last Name                                    First Name                                                             Middle Initial


   Title                                              Date of Birth                               SSN/FEIN                          Relationship to Primary


   Owner Address                                                                        City                                        State          Zip


   Monetary                                                                             Securities (stock)
   Category Code                                                                        Category Code
   Original Amount                                                                      CUSIP
   Deduction Amount                                                                     Number of Shares
   Deduction Type                                                                         Property Retained (Municipal Gov’t Only)
   Interest Rate 0%

                                                ID Number
                                                ID Number
                                                Last Activity Date

   Primary Owner Last Name                                      First Name                                         Middle Initial      Relation to 1st owner:


   Title                                              Date of Birth                               SSN/FEIN


   Complete Secondary Owner Information If There Is More Than One Owner For This Property

   Secondary Owner Last Name                                    First Name                                                             Middle Initial


   Title                                              Date of Birth                               SSN/FEIN                          Relationship to Primary


   Owner Address                                                                        City                                        State          Zip


   Monetary                                                                             Securities (stock)
   Category Code                                                                        Category Code
   Original Amount                                                                      CUSIP
   Deduction Amount                                                                     Number of Shares
   Deduction Type                                                                         Property Retained (Municipal Gov’t Only)
   Interest Rate 0%

                                                ID Number
                                                ID Number
                                                Last Activity Date


                                             Page               of                                   Page Total $

                                             Grand Total $
For assistance visit ucp.dor.wa.gov or call (360) 705-6706. To inquire about the availability of this document in an alternate format for the visually impaired,
please call (360) 705-6715. Teletype (TTY) users may call 1-800-451-7985.
REV 80 0008 (06/15/09)                                                                                                                         Print This Form