HOLDER:
FOR THE YEAR ENDED:
A. If you have NO unclaimed property to
report for this period, check here:
Federal I.D. Number:
Name of Company or Corporation:
Mailing Address:
Location Address:
City & State: Zip Code:
Contact Person: Telephone Number for Contact Person:
E-mail for Contact Person:
COD/CD 918 05/2016
(410) 767-1700 OR Toll Free 1(800) 782-7383
FAX: (410) 333-7150
B. If you DO have unclaimed property to report:
I declare under penalty of perjury that this report (including any accompanying schedules and statements)
has been examined by me and to the best of my knowledge is a true and complete report.
______________________________________ ____________________ ____________________
Signature Title Date
HOLDER NUMBER:
DUE DATE:
Unclaimed Property Unit
P.O. Box 17161
Baltimore, Maryland 21297-1161
Maryland Unclaimed Property Report
STATE OF INCORPORATION:
2. Use FORM COM/CD 919 to report:
● Individual accounts $100.00 and GREATER
● Securities (stocks, bonds, certificates, etc.)
● Safe Deposit Boxes
● 10 Accounts or less
1. Enter total dollar amount of all accounts LESS than $100.00 here: $
, unless you give a preferred telephone number here:
IMPORTANT: We will notify owners to call you about this report, at:
Enter total number of unclaimed accounts $100.00 and GREATER listed on FORM COM/CD 919 here:
