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)

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download