Fillable HOLDER INFORMATION (Nevada State Treasurer)

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HOLDER INFORMATION (Nevada State Treasurer)

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Nevada State Treasurer
Safe Deposit Box/Safekeeping Report Summary
Date:
Email:
Phone No.: Fax No.:
City: State: Zip:
UP-3 (10/2012)
Name of Authorized Officer
provided above and in the attached schedules is true and correct, that written notice was sent to owners, i.e., Due Diligence,
Signature of Authorized Officer
Date of Formation:
SUMMARY OF PROPERTY REPORTED AND REMITTED
Address:
VERIFICATION STATEMENT
Under penalty of perjury, I declare to the best of my knowledge and belief, that the safe deposit box/safekeeping information
Parent Company Federal/Tax ID No.:
Contact Person:
#
HOLDER INFORMATION
Nevada Business ID:
Check only one : Insurance Annual Report [ ] Annual Report (all other entities) [ ]
Number of safe deposit boxes/safekeeping items reported:
Nevada Holder ID Number:
State of Formation:
Title/Department:
Entity Name:
Parent Company Name:
pursuant to NRS 120A.560, has been completed and that I am duly authorized to execute this verification by the instituition.
Receipt ID:
FOR OFFICIAL USE ONLY
Title of Authorized Officer
Date
Import Batch Number:
Report ID:
Clear Page
for any claim which then exists or which thereafter may arise or be made in respect to the property (NRS 120A.570).
- FOR BANK USE ONLY -
That thereafter the contents of such safe deposit box were:
[ ]
[ ]
.
[ ]
dated .
[ ]
[ ]
.
dated .
[ ] Other: .
day
of 20_____.
by
UP-3A (10/2012)
Charge for forcible entry
Nevada, this
In witness whereof, we have hereunto set our hands at
The Nevada State Treasurer, as the administrator of Unclaimed Property, takes custody of the contents shown for the above listed
owner(s) and is responsible for its safekeeping. The holder is relieved of all liability to the extent of the value of the property delivered
Signature of Holder Official
-$
Safekeeping Charge
Returned to the safe deposit box in total.
Returned to the safe deposit box with the exception of
Signature of Acceptor of Property
Signature of Notary Public
Contents turned over to the State of Nevada as Unclaimed Property under NRS120A.510 on this date ________
THIS SECTION TO BE USED IF CONTENTS BECOME UNCLAIMED
Sealed in a package by the undersigned notary public, together with a duplicate of this certificate and the name of the
Mailed to the lessee by certified or registered mail in accordance with lessee's written instructions dated:
lessee and the date of opening of the safe deposit box were written on the outside of the package by the undersigned
notary public in the presence of a bank officer, and a copy of this certificate was sent by certified mail, addressed to
the lessee at the last known address of the lessee (NRS 663.085).
Signature of State Official
Balance Owed by Renter
Unpaid Rent
-$
Date rent last paid:
Signature of Bank Officer
-$
-$
Released to
(Agency) in accordance with search warrant
in accordance with court order
which was released to
State of Nevada, County of
Signed and sworn to before me on
Clear Page
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HOLDER INFORMATION (Nevada State Treasurer)

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Completed 20 July 2020

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