Detail Report for Unclaimed Property - Washington

WARNING: To protect against the possibility of others accessing your confidential

Washington State Department of Revenue Unclaimed Property Section

PO Box 34053

Seattle, WA 98124-1053

360-534-1502 (option 4)

information, do not complete these forms on a public workstation.

Detail Report for Unclaimed Property

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Holder Name Holder Number

Report Year

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 Property

Category Code Original Amount Deduction Amount Deduction Type Interest Rate

Primary Owner Last Name

Municipal Reporting

Property Retained Per RCW 63.29.190

Additional Information

ID Number ID Number Last Activity Date

First Name

Securities (stock)

Category Code CUSIP Number of Shares

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 Property

Category Code Original Amount Deduction Amount Deduction Type Interest Rate

Municipal Reporting

Property Retained Per RCW 63.29.190

Additional Information

ID Number ID Number Last Activity Date

Securities (stock)

Category Code CUSIP Number of Shares

Page

of

Page Total $

Grand Total $

For assistance visit ucp.dor. or call 360-534-1502. To inquire about the availability of this document in an alternate format, please call

360-705-6705. Teletype (TTY) users may use the Washington relay Service by calling 711.

REV 80 0008 (7/12/19)

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