OFFICE OF UNCLAIMED FUNDS TH

AC2709 (Rev. 2/20)

New York State Comptroller OFFICE OF UNCLAIMED FUNDS

110 State Street, 8TH Floor Albany, NY 12236-0001

VERIFICATION AND CHECKLIST FOR UNCLAIMED PROPERTY

Reporting Organization: (name of business)

(area or department, e.g., Corp Trust Division) (street address) (street address)

(city, state, zip code) (service bureau, if used)

Verification for Period Ended

, 20

State of Incorporation

Date of Incorporation

Are You Authorized To Do Business in NYS?

FEDERAL EMPL ID NO:

Contact Person Contact Title

Contact Phone (

)

Contact Fax

(

)

Address

(service bureau contact name)

Email Address

(service bureau contact phone)

I certify that I am a duly authorized officer of the above named organization. To the best of my knowledge and belief this report is a true and complete statement of all abandoned property held by, or owing by, this organization as of the report period end date.

Signature

Payment Type: Electronic

Check

Securities

Totals: Cash Issues Shares

Amount Received

Date Received

Comments

RESERVED FOR USE OF STATE COMPTROLLER

Ack. Number

Media Type Class

Report Sequence

Year

Complete the "checklist" sheet, indicating types and amounts of property being reported. Detailed instructions for completing this form are in the Handbook for Reporters of Unclaimed Funds. Also, verify that the property type(s) used on this form are the same as the ones used in your detailed Report of Abandoned Property. For more information, see the Property Type Table.

1. ACCOUNT BALANCES

Dormancy Period

Cash

Shares/Units

A. B.

C. D. E. F. G.

H. I. K.

J.

Demand Deposit Account(s) Savings Accounts (includes Club Accounts, Security Deposits & Retirement Accounts) Time Deposit Accounts Money on Deposits to Security Funds (if separate from A & B) Unidentified Deposits (if separate from A & B) & Suspense Accounts

Escrow Funds (Mortgages, Performance Guarantee, Surety Bonds, etc.)

Credit Balances Arising from Loans (includes Liquidated Mortgages, Consumer Loans, Remainder of Collateral Amounts, etc.) Credit Balances; Consumer Credit Accounts

Credit Balances in Trading & Investment Accounts with Trusts, Brokers, Investment Firms, etc. (Including O/S checks issued to customers), Virtual Currency Wallet Balances (non-US Dollar) Credit Balances or Cash Due Renters of Safe Deposit Boxes

3 yrs

3 yrs 3 yrs 3 yrs 3 yrs 3 yrs

3 yrs 3 yrs

3 yrs 3 yrs

1A. $

1B. $ 1C. $ 1D. $ 1E. $ 1F. $

1G. $ 1H. $

1I.

$

1J. $

1K. _______________

2. NEGOTIABLE INSTRUMENTS

A.

Certified Checks

3 yrs 2A. $

B.

Cashier, Teller Checks

3 yrs 2B. $

C.

Bank Money Orders

3 yrs 2C. $

D.

Treasurer & Registered Checks

3 yrs 2D. $

E.

Drafts & Bank Traveler's Checks

3 yrs 2E. $

F.

Warrants

3 yrs 2F. $

G.

Outstanding Checks Issued to Vendors (Accounts Payable)

3 yrs 2G. $

H.

Travelers Checks (non-bank)

15 yrs 2H. $

I.

Licensed Money Transmitter Receipts & Money Orders (non-bank)

5 yrs 2I. $

J

State Checks

1 yr

2J. $

3. PAYING AGENTS, FIDUCIARY, MUTUAL FUNDS, AMERICAN DEPOSITARY RECEIPT ACCOUNTS AND CORPORATION DISBURSING DIRECTLY TO THEIR OWN SHAREHOLDERS

A. B. C. P.

D. Q. E. F. R. G. S. H. T. I. U.

Cash Dividends (other than ADR)

Bond Interest (other than ADR) Stock Dividends (other than ADR) Distributions from Ownership of Interest (other than ADR), includes Redemption Values, Warrants, Underlying & Unexchanged Shares & Accrued Dividends Cash Dividends (ADR) Stock Dividends (ADR) Other Distributions Resulting From Ownership of Interest (ADR) Bond Redemption Mutual Fund & Dividend Reinvestment)

3 yrs

3 yrs 3 yrs

3A. $ ___________________

3B. $

3C. $

3P.

3 yrs 3D. $

3Q.

3 yrs 3E. $

3 yrs 3F. $

3R.

3 yrs 3G. $

3S.

3 yrs 3H. $

3T.

3 yrs 3I. $

3U.

4. INVESTMENTS, TRADING (BROKER/DEALER) AND BANK TRUST DEPARTMENT ACCOUNTS REPRESENTING DISTRIBUTIONS RECEIVED FOR KNOWN AND UNKNOWN OWNERS

A. B. C. P. D. Q. E. R. F. S.

Cash Over Receipts (Dividends & Other)

3 yrs 4A. $ ___________________

Bond Interest Over Receipts

3 yrs 4B. $ ___________________

Stock Over Receipts (Dividends & Other)

3 yrs 4C. $

4P.

Other Over Receipts

3 yrs 4D. $

4Q.

Unidentified Overages

3 yrs 4E. $

4R.

Other Distributions Resulting from Ownership Interest or Debt Obligation 3 yrs 4F. $

4S.

5. REFUNDS

A.

Utility Service Deposit

B.

Advance Payments for Utility Services Not Furnished

C.

Refunds Due on Overcharges by Utility Companies

D.

Refunds Due by Insurance Companies

E.

Amounts Due for Undelivered Goods and/or Services

F.

Rebates

2 yrs 5A $ 2 yrs 5B. $

2 yrs 5C. $ 3 yrs 5D. $ 3 yrs 5E. $ 3 yrs 5F. $

6. INSURANCE PROCEEDS

A.

Limiting Age (Superannuated) Contracts

B.

Matured Endowments

C.

Death Claims

D.

Amounts Due Under Policies of Insurance Other than Life

E.

Refunds & Other Amounts Due Under Policy Terms

F.

Annuities

G.

Retained Asset Accounts, Benefits Access Accounts, or similar

distribution accounts

None 6A. $ ___________________ 3 yrs 6B. $ ___________________ 3 yrs 6C. $ 3 yrs 6D. $ 3 yrs 6E. $ 3 yrs 6F. $ 3 yrs 6G. $

7. FUNDS OWING BY COURTS AND GOVERNMENTAL UNITS

A.

Trust Funds

B.

Bail Funds

C.

Funds for Support of Spouse or Child

D.

Condemnation Awards

X.

Other

3 yrs

3 yrs 3 yrs 3 yrs 3 yrs

7A. $

7B. $ 7C. $ 7D. $ 7X. $

8. OTHER AMOUNTS AND SECURITIES

A. B.

C. D. E. F. P. G. Q. H. R. I. S. J. T. K. U. X. Y. Z.

Wages, Payroll, Salaries, Commissions, Pension Payments

3 yrs 8A.

Unredeemed Gift Cards (5yrs ) Merchandise, Credits, Lay-Away Deposits,

AR and AP Credits on Cards (3yrs)

3/5 yrs 8B.

Amounts Owed by Sales & Insurance Finance Companies

3 yrs 8C.

Surplus from Sale of Pledged Property

1/3 yrs 8D.

Lost Property

3 yrs 8E.

Securities Long in Customers' Trading, Investment, Trust Accounts

3 yrs 8F.

Securities Held as Transfer Agent

3 yrs 8G.

Securities Held in a Vault or Storage Area of a Bank

3 yrs 8H.

Securities Lost & held by a Safe Deposit Company or Bank

3 yrs 8I.

Securities Found in a Safe Deposit Box

3 yrs 8J.

Other Securities Owed

3 yrs 8K.

Late Filing Interest

None 8X.

Other Miscellaneous Property

2 yrs 8Y.

$

$ ___________________

$

$

$

$

8P.

$

8Q.

$

8R.

$

8S.

$

8T.

$

8U.

$

$

8Z.

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