STATE OF TENNESSEEwTREASURY DEPARTMENT
Unclaimed Property Division
P.O. Box 198649wNashville, Tennessee 37219-8649w(615) 253-5362
www.tn.gov/treasury/unclaim
REPORT OF PROPERTY
DISTRIBUTEES WHO CANNOT BE LOCATED OR WHO REFUSE DISTRIBUTION
This report is to be filed in accordance with T. C. A. § 30-2-702. (See next page)
A separate Report of Property must be completed for each distributee of the decedent’s estate who cannot be
located or who otherwise cannot receive a distribution to which the distributee is entitled due to one of the
other circumstances listed in T.C.A. § 30-2-702.
Part I - Give FULL Information on Decedent _________________________
Date of Death
Name
____________________________________________________________________________________________________
Last First Middle Maiden
Address
____________________________________________________________________________________________________
Street City State Zip Code County
Part II - Give FULL Information on Distributee
Name
____________________________________________________________________________________________________
Last First Middle Maiden
Social Security Number ________________________ Phone Number _______________________
Address
____________________________________________________________________________________________________
Street City State Zip Code County
Part III - List ALL Property Distributable to Distributee from Decedent’s Estate
Description Value
1. ____________________________________________________________________ $ _____________________
2. ____________________________________________________________________ $ _____________________
3. ____________________________________________________________________ $ _____________________
4. ____________________________________________________________________ $ _____________________
5. ____________________________________________________________________ $ _____________________
Attach additional schedule if necessary.
Reason why final settlement of decedent’s estate cannot be made: (e.g., cannot locate distributee, distributee
refused distribution, or distributee is deceased and no personal representative of the deceased distributee exists)
____________________________________________________________________________________________________
_____________________________________________________________________________________
Attach probated will (or if one does not exist, the court order) reflecting devise to distributee.
Report filed by: _________________________________________________________________________
Relationship to decedent: _________________________________________________________________
Address: ______________________________________________________________________________
Street City State Zip Code
Phone Number: ________________________ E-Mail Address ____________________________
TR 0400 RDA 2128(Continued on next page)
