Unclaimed Property Report Form - Missouri

HOW TO COMPLETE THIS REPORTSection A: Holder Reporting InformationPART I REPORT INFORMATION DATE PREPARED - The date the Report is completed. REPORT PERIOD ENDING - Period ending date covered bythis report. Example, the report for the period ending June 30is due November 1. For life insurers, the reporting periodending December 31 is due on May 1. FEDERAL I.D. - Provide your federal identification number ortaxpayer identification number. HOLDER NUMBER - Enter your Holder Number, which is theseven-digit number on the front of the postcard. Leave thisspace blank if your Holder Number is unknown or unavailable. TOTAL NO. ITEMS/SHARES/SAFE DEPOSIT BOXES Enter the total number of owners, shares, and safe depositboxes included in Section B of the Report. CHECK NUMBER - The number of the check accompanyingthis Report. CHECK AMOUNT - Amount of payment being remitted, whichis the Grand Total of all property items as recorded on the lastpage of Section B of the report (less Expenses, if applicable).Checks are to be made payable to the Missouri StateTreasurer’s office. Please submit one check for the GrandTotal. Remittance must accompany the Report.PART II HOLDER INFORMATION NAME OF HOLDER - Name of the company remitting theReport. If there is a label on the cover of this booklet, itshould be peeled off and affixed to the area labeled HOLDERINFORMATION. This label includes the seven-digit holdernumber. Make corrections as necessary. MAILING ADDRESS, CITY, STATE, ZIP, COUNTY - Addressused by the Holder to receive mail, to include the county. STATE OF INCORPORATION - State in which company isincorporated. DATE OF INCORPORATION - Date company wasincorporated. PRIMARY PLACE OF BUSINESS IN MISSOURI - Locationof main business activity within this state. Please be asspecific as possible. If reporting for a single branch, pleaseprovide the physical address of the branch location.PART III PREVIOUS HOLDER INFORMATIONThis section is to be used by a Holder that has had a namechange or merger, or if the Holder is a successor to otherentities who previously held the property for the owner. Listprevious holder numbers, names and/or addresses underwhich you have previously filed Unclaimed Propertyreports with the Missouri State Treasurer’soffice.PART IV PRIMARY BUSINESS ACTIVITYPlease provide a brief summary that best describes yourorganization’s primary business activity.4PART V CONTACT PERSONThe contact person listed on the report is the name ofthe individual who prepared the report or whom theMissouri State Treasurer’s office can contact in the eventthere are any questions relating to the report.PART VI AUTHORIZATIONThe individual authorized to submit the Report of UnclaimedProperty on behalf of the Holder.Section B: Summary of Unclaimed Property HOLDER NUMBER and HOLDER NAME - Enter your HolderNumber and Holder Name as they appear in Section A ofthis Report. Leave the Holder Number space blank if it isunknown or unavailable. REPORT PERIOD ENDING - Enter the period ending datefor which this report is being filed. Date should correspondwith the reporting period listed in Section A of this report. ORIGINAL OWNER NAME - Last name, first name andmiddle name or initial, as available. Be sure to include anyinformation that would aid in the identification of the owner, toinclude Jr., Sr., Dr., etc. (for example, Smith Jane Ann MD).Company names or corporate titles should be entered exactlyas adopted, except the word “the” should be omitted when itis the first word of the title. If a single item has two or moreowners, the names and addresses of each must be listed.When reporting certified checks or cashiers checks, list thenames and addresses of both remitter and payee if available,specifying each. If no owner name is available, reportthe property as “Unknown” (include any other identifyinginformation that may be available in the respective columns).Items that are 50 or less may be reported in Aggregatetotals by property type at the end of the report rather thanindividually. However, since our goal is to return as muchproperty as possible to the rightful owners, we encouragethe reporting of detailed owner information whenever it isavailable. OWNER RELATIONSHIP - Relationship of each ownerlisted (e.g. OWNER, JT TEN, CUSTODIAN, MINOR, PAYEE,REMITTER). Refer to Owner Relationship Codes table. OWNER ADDRESS - Include street, city, state, zip andcounty, if available, of the last known address of the originalowner. If no address is available, write the word “Unknown” inthe address column. SS NUMBER/DATE OF BIRTH - Provide original owner’ssocial security number or taxpayer id number and date ofbirth if available. ACCOUNT/CHECK NUMBER - Enter any identificationnumber(s) available regarding the property item, suchas account number, policy number, check number, stockcertificate number, etc. PROPERTY DESCRIPTION - Enter the property descriptionof each item (e.g., Payroll checks, Savings Accounts, SafeDeposit Box Contents, etc.). Refer to Property Type Codesfor listing of categories and descriptions. In the case of safe deposit boxes, attach separate inventorysheets identifying contents, including a description of the

HOW TO COMPLETE THIS REPORTcontents (e.g., “4 insurance policies, 1 goldtone ring, and 2letters”). Indicate in Section B “Safe Deposit Box informationattached.”For securities, please include the issuing company name andnumber of shares remitted for each owner. PROPERTY CODE - Enter the appropriate property codefor each type of unclaimed property according to PropertyType Codes. Items that are 50 or less may be reported inAggregate within the appropriate category (e.g., “Aggregateof 5 items less than 50, Vendor Checks, Code 56, total 156.00”). DATE OF LAST TRANSACTION/DATE PROPERTYBECAME PAYABLE, REDEEMABLE OR RETURNABLE Indicate date of last owner-initiated activity on account, dateof check, or date of maturity. CHECK IF INTEREST-BEARING - Check box if account wasaccruing interest at the time of remittance, or if the ownerwould have been entitled to interest had the property notbeen presumed abandoned. AMOUNT DUE OWNER - Enter the total amount of cashvalue due the owner, including any interest earned ondeposits. PAGE TOTAL - Enter the sum of the Amount Due Ownercolumn for each page. GRAND TOTAL - To be entered on the last page of thereport. The Grand Total is the sum of the Page Totals fromeach page of Section B of the report. DEDUCTED EXPENSES SUMMARY - This space maybe used by the Holder pursuant to the Missouri UnclaimedProperty Statute (RSMo 447.543). Expenses deducted mustbe itemized (expense description and amount). Allexpenses must be approved by the Missouri StateTreasurer’s office. If expenses are reported, deduct theexpense total from the Grand Total to obtain the totalamount of remittance. Please contact the Missouri StateTreasurer’s office for an explanation of allowable expensedeductions.HOLDER REIMBURSEMENTS AND REFUNDSPeriodically an owner will contact the Holder after their propertyhas already been reported and remitted to the Missouri StateTreasurer’s office. If the owner is then paid or the accountreinstated by the Holder, the Holder may submit a request forreimbursement to the Missouri State Treasurer’s office. Proof ofpayment or account reinstatement is required for reimbursement.Refunds will be issued to Holders who have overpaid theirunclaimed property report because of an accounting error or othermistake made during the preparation of the report. To request arefund, make a written request to the Missouri State Treasurer’soffice and explain the nature of the mistake. Includedocumentation with your request that supports your explanation ofthe error.If the amount remitted is less than the amount reported and noexplanation is provided, a request for additional remittance will besubmitted by the Missouri State Treasurer’s office to the holder.The additional payment must be remitted to the Missouri StateTreasurer’s office within 30 days of the request to the MissouriState Treasurer’soffice and explain the nature of the mistake.Include documentation with your request that supports yourexplanation of the error.Property Type CodesACCOUNT BALANCES DUECHECKING ACCOUNTSAC01AC02SAVINGS ACCOUNTSAC03MATURED CD OR SAV CERT.AC04CHRISTMAS CLUB FUNDSAC05MONEY ON DEP TO SECURE FUNDAC06SECURITY DEPOSITSAC07UNIDENTIFIED DEPOSITSAC08SUSPENSE ACCOUNTSAC09MONEY MARKETAC99AGG. ACCT. BALANCES UNDER 50CK15CK16CK99UNCASHED CHECKSCK01CASHIERS CHECKSCK02CERTIFIED CHECKSCK03REGISTERED CHECKSCK04TREASURERS CHECKSCK05DRAFTSCK06WARRANTSCK07MONEY ORDERSCK08TRAVELERS CHECKSCK09FOREIGN EXCHANGE CHECKSCK10EXPENSE CHECKSCK11PENSION CHECKSCK12CREDIT CHECKS OR MEMOSCK13VENDOR CHECKSCK14CHECKS WRITTEN OFF TO INCOMEINSURANCEIN01IND. POLICY BENEFITS/CLM. PAYMENTSIN02GRP. POLICY BENEFITS/CLM. PAYMENTSIN03PROCEEDS DUE BENEFICIARIESIN04PROCEEDS FROM MATURED POLICIES, ENDOWMENTS,OR ANNUITIESIN05PREMIUM REFUNDSIN06UNIDENTIFIED REMITTANCESIN07OTHER AMTS. DUE UNDER POLICY TERMSIN08AGENT CREDIT BALANCESIN99AGG. INSURANCE PROPERTY UNDER 50OTH. OUTSTANDING OFFICIAL CKS.CD INTEREST CHECKSAGG. UNCASHED CKS. UNDER 50COURT DEPOSITSCT01ESCROW FUNDSCT02CONDEMNATION AWARDSCT03MISSING HEIRS FUNDCT04SUSPENSE ACCTS.CT05OTHER COURT DEPOSITSCT06PUBLIC AID CHILD SUPPORT CKS.CT99AGG. COURT DEPOSITS UNDER 50CONTINUED.5

SC09SC10SC11SC12SC13MINERAL PROCEEDS & MINERAL INTERESTSMI01NET REVENUE INTERESTMI02ROYALTIESMI03OVERRIDING ROYALTIESMI04PRODUCTION PAYMENTSMI05WORKING INTERESTMI06BONUSESMI07DELAY RENTALSMI08SHUT-IN ROYALTIESMI09MINIMUM ROYALTIESMI99AGG. MINERAL INTERESTS UNDER MISC. CHECKS & INTANGIBLE PERSONAL PROP.MS01WAGES, PAYROLL, SALARYMS02COMMISSIONSMS03WORKERS’ COMP. BENEFITSMS04PAYMENT FOR GOODS & SERVICESMS05CUSTOMER OVERPAYMENTSMS06UNIDENTIFIED REMITTANCESMS07UNREFUNDED OVERCHARGESMS08ACCOUNTS PAYABLEMS09CREDIT BALANCES- ACCTS RECEIVABLEMS10DISCOUNTS DUEMS11REFUNDS DUEMS12UNREDEEMED GIFT CERTIFICATESMS13UNCLAIMED LOAN COLLATERALMS14PENSION & PROFIT SHARING PLANSMS15DISSOLUTION OR LIQUIDATIONMS16MISC OUTSTANDING CHECKSMS17MISC INTANGIBLE PROPERTYMS18SUSPENSE LIABILITIESMS99AGG. MISC. PROPERTY UNDER 50CASH FOR FRACTIONAL SHARESUNEXCHANGED STOCK/SUCCESSOR CO.OTHER CERT. OF OWNERSHIPUNDERLYING SHARES OR OTHER OUTSTANDING CERTS.FUNDS FOR LIQ./REDEMPTION OF UNSURRENDEREDSTOCKS OR BONDSDEBENTURESUS GOVT SECURITIESMUTUAL FUND SHARESWARRANTS (RIGHTS)MATURED BOND PRINCIPALDIVIDEND REINVESTMENT PLANSCREDIT BALANCESSUM OF VAR. STOCK RELATED CASH ITEMSCASH IN LIEUSUM OF VAR. STOCK RELATED STOCK ITEMSMONEY MARKETAGG. SECURITY RELATED CASH UNDER 50SAFE DEPOSIT BOXES & SAFEKEEPINGSD01SAFETY DEPOSIT BOX CONTENTSSD02OTHER SAFEKEEPINGSD03OTHER TANGIBLE PROPERTYTRUST, INVESTMENT AND ESCROW ACCOUNTSTR01PAYING AGENT ACCTS.TR02UNDELIVERED OR UNCASHED ITEMSTR03FUNDS HELD IN FIDUCIARY CAPACITYTR04ESCROW ACCTS.TR05TRUST VOUCHERSTR06PRE-NEED FUNERAL PLANSTR99AGG. TRUST PROP. UNDER 50SECURITIESSC01DIVIDENDSSC02INTEREST (BOND COUPONS)SC03PRINCIPAL PAYMENTSSC04EQUITY PAYMENTSSC05PROFITSSC06FUNDS PD TO PURCHASE SHARESSC07FUNDS FOR STOCKS & BONDSSC08SHARES OF STOCK (RETURNED BY P.O)UTILITIESUT01UTILITY DEPOSITSUT02MEMBERSHIP FEESUT03REFUNDS OR REBATESUT04CAPITAL CREDIT DISTRIBUTIONSUT99AGG. UTILITY PROPERTY UNDER 50ZZZZPROPERTIES NOT IDENTIFIED ABOVE(WRITTEN DESCRIPTION MUST ACCOMPANY)Owner Relationship CodesOWNER RELATIONSHIP pendentESEstate ofEXExecutorFBFor Benefit ofGUGuardian6INJTMNOROWPAPDPRPYInsuredJoint TenantMinorOROwnerPower of AttorneyPay on DeathPersonal uretyTenants in CommonTransfer on DeathTrustee ofTrusteeUniform Gifts to Minor Act

OFFICE OF THE MISSOURISTATE TREASURERMAIL COMPLETED REPORT AND REMITTANCE TO:MISSOURI STATE TREASURER'S OFFICEUNCLAIMED PROPERTYP.O. BOX 1272JEFFERSON CITY, MISSOURI 65102-1272REPORT OF UNCLAIMED PROPERTYSECTION AHOLDER REPORTING INFORMATIONPART I REPORT INFORMATIONDATE PREPAREDTOTAL NO. OF ITEMSREPORT PERIOD ENDINGTOTAL NO. OF SHARESTOTAL NO. OF SAFEDEPOSIT BOXESFEDERAL I.D. NUMBERHOLDER NUMBERCHECK NUMBERCHECK AMOUNTPART II HOLDER INFORMATIONTHIS REPORT INCLUDES:AFFIX LABELALL BRANCHES AND DIVISIONSALL SUBSIDIARIESONLY THIS COMPANY/BRANCH/DIVISIONNAME OF HOLDERSTATE OF INCORPORATIONMAILING ADDRESSDATE OF INCORPORATIONCITY STATE ZIP COUNTYPRIMARY PLACE OF BUSINESS IN MISSOURI (CITY, COUNTY, ZIP)PROVIDE PREVIOUS HOLDER INFORMATION IF YOU ARE A SUCCESSOR TO PREVIOUS HOLDERS OF THE PROPERTY. IF YOU HAVECHANGED YOUR NAME OR ADDRESS DURING THE TIME PERIOD THAT YOU HAVE HELD THE PROPERTY, LIST THE PRIOR NAME(S) ANDADDRESS(ES) YOU HAVE REPORTED UNDER.PART III PREVIOUS HOLDER INFORMATIONPREVIOUS NAME OF BUSINESSFEDERAL I.D. NO.HOLDER NUMBERDATE OF CHANGEPREVIOUS ADDRESS (STREET, CITY, STATE, ZIP)PART IV PRIMARY BUSINESS ACTIVITY INFORMATIONPLEASE PROVIDE A BRIEF BUSINESS DESCRIPTIONPART V CONTACT PERSONCONTACT PERSONTITLEPHONE NUMBER EXTENSIONFAX NUMBERPART VI AUTHORIZATIONI, being first duly sworn under oath, state that I have examined this reportof property presumed abandoned under the Missouri Unclaimed Property Act, and that I am duly authorized by the Holder herein toexecute this report; and I declare by penalty of perjury that this report is true, correct, and complete, as of said date.SIGNATURETITLENOTE: This verification, if made by a partnership, shall be executed by a partner; if made by an unincorporated association or privatecorporation, by an officer; and if made by a public corporation, by its chief fiscal officer.MO 272-1112 (8-98)FOR OFFICE USE ONLYPROCESSED BY VERIFIED BY KEYED BY

OWNER STREETADDRESSCITY, STATE, ZIP,COUNTYOWNER SOCIALSECURITYNUMBER AND/ORDATE OF BIRTHHOLDER NUMBERAMOUNTAMOUNTITEM DESCRIPTIONITEM DESCRIPTIONIf expenses have been deducted per RSMo 447.543, please outline these costsbelow:ACCT/CHECKNUMBERHOLDER NAME(SEE APP. A)PROP CODENO. ITEMS THIS PAGEPROPERTYDESCRIPTIONDATE OF LASTTRANSACTION.DATE PROP.BECAME PAYABLE,REDEEMABLE, ORRETURNABLEGRAND TOTAL(IF LAST PAGE)PAGE TOTALCHECK THIS BOXIF INTERESTBEARINGACCOUNTREPORT PERIOD ENDINGFILE THIS REPORT WITH YOUR REMITTANCE ON NOVEMBER 1 (MAY 1 FOR LIFE INSURERS).ALL ITEMS LESS THAN 50 MAY BE REPORTED IN AGGREGATE AND ENTERED BY PROPERTYTYPE AT THE END OF THIS REPORT.DEDUCTED EXPENSES SUMMARY NONE DEDUCTEDORIGINAL OWNERNAME(LIST BY LAST NAME,FIRST NAME, MI)(IF ADDITIONAL SPACE IS REQUIRED, PLEASE DUPLICATETHIS FORM)SEE INSTRUCTIONSSUMMARY OF UNCLAIMED PROPERTYSECTION B AMOUNTDUEOWNERPAGE NOof

Unclaimed Property Report Checklist1. Have you completed sections A and B of this report?2. Have you verified that the total of the individual properties equals the total amountof your check?3. Are you deducting expenses? If so, please complete the expense summary inSection B and adjust your totals accordingly.4. Have you checked the box for interest bearing accounts as applicable?5. Is your check made payable to Office of the Missouri State Treasurer and attachedto your report?6. Are the following included in your report:STOCK CERTIFICATESSAFE DEPOSIT BOX CONTENTSOWNER DETAIL LISTING (HARDCOPY AND/OR DISKETTE)7. Did you include all names, addresses, zip codes and social security numbers thatare available for owner accounts?9

Anyone requiring assistance in completing this form or who has questions relating to the Unclaimed Property Act or the filing of the Unclaimed Property report, please do not hesitate to contact my staff at the address below: Missouri State Treasurer's Office Unclaimed Property Division P.O. Box 1272 Jefferson City, MO 65102-1272 (573)751-0123