Washington State Department of Revenue Negative Report
[Pages:1]Washington State Department of Revenue Unclaimed Property Section
PO Box 34053
Seattle, WA 98124-1053
(360) 705-6706
WARNING:To protect against the possibility of others accessing your confidential information, do not complete these forms on a public workstation.
Negative Report
for Unclaimed Property
Reset This Form
4 Please print clearly and use black ink only
Address change Business Name: Attn or in care of: Mailing Address:
Report and Payment Due by November 1
Washington Holder Number
Federal ID Number
Report Year
Sequence Number
Date & State of Incorporation
UBI Number
Primary Business Activity
City, State, Zip:
Date Received (office use only)
Contact Person:
Name
Telephone Number
E-mail
No Property to Report: Inactive Account:
Close Account:
Check here if you do not have any property to report, then complete the declaration below.
Check here if you do not anticipate having property to report. NOTE: You will need to request report forms, if you need to report in the future.
Check here if your business is closing or is closed.
Report Declaration:
I declare that this report, including attachments, has been examined by me. I am duly authorized by the holder herein to execute this report and that I believe said report is true, correct, and complete for the stated period.
Signature
Title
Date
NEGATIVE REPORT INSTRUCTIONS
Print This Form
Holder Reporting Number, Name and Address: Enter business name and address. This address will be used for future reports or correspondence regarding unclaimed property. Name and Address Change: Enter the correct name and address above. Attach a list of subsidiaries that are reporting under the same holder name. Washington Holder Number: Enter your holder number. For first time reporters, leave blank. A holder number will be assigned. Federal ID Number (FEIN): Enter your nine digit FEIN. Current Year: Enter the current year. Date and State of Incorporation: Enter your date and state of incorporation. Unified Business Identifier (UBI): Enter your Washington State (UBI), if known. Primary Business Activity: Briefly describe your primary business activity. Contact Person: Enter the name, telephone number, and e-mail address of contact person. No Property to Report: Check this box if you have nothing to report for the reporting year. Inactive Account: You do not have property to report for this year and do not expect to report in the near future. Close Account: Check this box if your company has closed or merged with another company. Report Declaration: This report must be signed by an authorized individual.
For assistance visit ucp.dor. 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 0050 (06/15/09)
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