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ARIZONA FORM
650A
Entity Name (Holder)
E-Mail Address
4a. I have attached a true and correct list (Schedule A) of individual owners and properties, in accordance with A.R.S. § 44-307(B).
Reporting software is available for free download on our website www.azunclaimed.gov.
4b. I have reviewed and understand the State of Arizona payment protocols (see Arizona Unclaimed Property Reporting Manual)
The relationship codes reported for each property will allow accurate payment to the reported owners.
4c. Written notice has been sent to the owners of all properties being reported/remitted in accordance with A.R.S. § 44-307(E).
Name
Direct Telephone Number
Name
E-mail Address
Arizona Department of Revenue • Unclaimed Property Section
REPORT OF ABANDONED PROPERTY
DATE STAMP
Customer Contact (for use by owners of reported property)
Summary of
Abandoned Property Report
Telephone Number emaS
If you are remitting securities, please use Arizona Form 650B
If you are remitting safe deposit box contents, please use Arizona Form 650C
Total amount of properties over $50 with known owners
Total amount of report
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you do not aggregate these funds in your report.
Total amount of properties with unknown owners
Print Name Signature Date
I hereby certify that I have the authority to execute this report of Unclaimed Property on behalf of the above named holder. I declare under penalty of
perjury that the foregoing information, the information set forth in the schedules, and all documentation I have or will provide is true and complete.
State/Date of Incorporation
Previous Holder - If you are a successor to a previous holder
Report Type
Annual Report Life Insurance
Contact Person - For questions from staff members of the Arizona Department of Revenue
Title
Mailing Address
City State ZIP code
Federal ID Number
Prior Name - If Entity Name has changed
ADOR 10755 (8/11)
FOR DEPARTMENT USE ONLY
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Mailing address: Arizona Unclaimed Property Section 1600 West Monroe Street, Phoenix, AZ 85007