Commonwealth of Virginia Department of the Treasury Unclaimed …
Commonwealth of Virginia Department of the Treasury Unclaimed Property Division
Fax to: (804) 786-4653 Or Mail to: P. O. Box 2478 Richmond , VA 23218
Request for participation in the Commonwealth of Virginia Unclaimed Property Voluntary Compliance Program: Company Name______________________________________________________________ Address:___________________________________________________________________ City:______________________________State:____________Zip Code:_________________ State of Incorporation of Company: ______________________________________________ Location of Accounting Records (City, State):_______________________________________ FEIN for Company: ___________________________________________________________ Number of Employees: __________________Number located in Virginia:________________ Industry Type: _______________________________ NAICS:_______________________
Requested By:____________________________________ Title:____________________________________________ Date:____________________________________________ Contact Name:____________________________________ Telephone Number:________________________________ Fax Number:_____________________________________ E-mail Address:___________________________________
To be completed by the Division of Unclaimed Property: Date assigned: _____________________ Received by: ______________________ Participation number assigned: ________
REV. 11/2019
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